Provider Demographics
NPI:1831126143
Name:WISE, ROBERT LANCE (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LANCE
Last Name:WISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9104 E 62ND ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6443
Mailing Address - Country:US
Mailing Address - Phone:918-461-9490
Mailing Address - Fax:918-461-9690
Practice Address - Street 1:9104 E 62ND ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6443
Practice Address - Country:US
Practice Address - Phone:918-461-9490
Practice Address - Fax:918-461-9690
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3539111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU80223Medicare UPIN