Provider Demographics
NPI:1760674022
Name:WISDOM, JULIE HARDING (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:HARDING
Last Name:WISDOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BLANCO
Mailing Address - State:TX
Mailing Address - Zip Code:78606-4913
Mailing Address - Country:US
Mailing Address - Phone:830-833-5581
Mailing Address - Fax:
Practice Address - Street 1:21 SPURS LN
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1669
Practice Address - Country:US
Practice Address - Phone:210-614-6070
Practice Address - Fax:210-615-6814
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05313363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant