Provider Demographics
NPI:1750313375
Name:WISE, RUSSELL J (FNP)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:J
Last Name:WISE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 S ZAPATA HWY
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78046-6510
Mailing Address - Country:US
Mailing Address - Phone:956-795-8101
Mailing Address - Fax:956-795-8195
Practice Address - Street 1:2007 S ZAPATA HWY
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78046-6510
Practice Address - Country:US
Practice Address - Phone:956-795-8101
Practice Address - Fax:956-795-8195
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX633018363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157631602OtherCSHCN
TX157631601Medicaid
TX081896501Medicaid
TX092953101Medicaid
TX451962Medicare Oscar/Certification
TX451961Medicare Oscar/Certification
TX451960Medicare Oscar/Certification
TX00CH47Medicare Oscar/Certification
TX451838Medicare Oscar/Certification
TX157631602OtherCSHCN
TX451963Medicare Oscar/Certification
TX092953101Medicaid
TX081896501Medicaid