Provider Demographics
NPI:1598836504
Name:WISE, MARIA A (DO)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:A
Last Name:WISE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84026
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-8426
Mailing Address - Country:US
Mailing Address - Phone:206-861-8500
Mailing Address - Fax:
Practice Address - Street 1:2211 QUEEN ANNE AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-2367
Practice Address - Country:US
Practice Address - Phone:206-861-8500
Practice Address - Fax:206-861-8501
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8348245Medicaid
WA8348245Medicaid
WA8867051Medicare PIN
WA8803321Medicare PIN