Provider Demographics
NPI:1760882732
Name:WISE, JOHN (PT, MAT, LMT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:PT, MAT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3506
Mailing Address - Country:US
Mailing Address - Phone:614-395-9369
Mailing Address - Fax:
Practice Address - Street 1:112 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-3506
Practice Address - Country:US
Practice Address - Phone:614-395-9369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH004954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist