Provider Demographics
NPI:1528416450
Name:WISE, BRENNA CHRISTINE (NP)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:CHRISTINE
Last Name:WISE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W 34TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705
Mailing Address - Country:US
Mailing Address - Phone:512-279-6749
Mailing Address - Fax:512-298-1795
Practice Address - Street 1:1111 W 34TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705
Practice Address - Country:US
Practice Address - Phone:512-324-3405
Practice Address - Fax:512-458-5446
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131507363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX376643801Medicaid