Provider Demographics
NPI:1629418173
Name:WISE, MARK ALLEN (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:WISE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3607 N EVERBROOK LANE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304
Mailing Address - Country:US
Mailing Address - Phone:765-741-8390
Mailing Address - Fax:765-741-8219
Practice Address - Street 1:3607 N EVERBROOK LANE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304
Practice Address - Country:US
Practice Address - Phone:765-741-8390
Practice Address - Fax:765-741-8219
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ05004768A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN156612Medicare UPIN