Provider Demographics
NPI:1821689365
Name:WISE, MATTHEW AMOS (NP-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:AMOS
Last Name:WISE
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:360 N IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-2808
Mailing Address - Country:US
Mailing Address - Phone:843-667-9414
Mailing Address - Fax:843-667-9414
Practice Address - Street 1:520 THURGOOD MARSHALL HWY STE B
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-4108
Practice Address - Country:US
Practice Address - Phone:846-355-5628
Practice Address - Fax:843-355-5616
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC24626363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily