Provider Demographics
NPI:1679850044
Name:WISE, KONTASHA SHAMIKA (ARNP)
Entity Type:Individual
Prefix:
First Name:KONTASHA
Middle Name:SHAMIKA
Last Name:WISE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8226 MENAUL BLVD NE # 144
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4614
Mailing Address - Country:US
Mailing Address - Phone:505-554-2681
Mailing Address - Fax:
Practice Address - Street 1:2900 LOUISIANA BLVD NE STE J1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3575
Practice Address - Country:US
Practice Address - Phone:505-554-2681
Practice Address - Fax:505-213-2657
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-12
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP02817363LA2200X, 363LF0000X, 363LP2300X, 363LP0808X
SC17616363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM6929753Medicaid
SCAA85907951Medicaid