Provider Demographics
NPI:1518176247
Name:WISE, ANDREW JOSEPH (LMP)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:JOSEPH
Last Name:WISE
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-3042
Mailing Address - Country:US
Mailing Address - Phone:206-714-9426
Mailing Address - Fax:
Practice Address - Street 1:11911 NE 132ND ST STE 101
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2900
Practice Address - Country:US
Practice Address - Phone:425-814-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024061225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist