Provider Demographics
NPI:1679060818
Name:WISE, BRADLEY WILLIAM
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WILLIAM
Last Name:WISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 E 9TH AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-3902
Mailing Address - Country:US
Mailing Address - Phone:303-388-2922
Mailing Address - Fax:303-388-2962
Practice Address - Street 1:4545 E 9TH AVE STE 120
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3902
Practice Address - Country:US
Practice Address - Phone:303-388-2922
Practice Address - Fax:303-388-2962
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0063626208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery