Provider Demographics
NPI:1851441216
Name:WISE, SAMUEL A (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3201 S MARYLAND PKWY
Mailing Address - Street 2:SUITE 218
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2441
Mailing Address - Country:US
Mailing Address - Phone:702-893-0800
Mailing Address - Fax:702-893-0109
Practice Address - Street 1:3201 S MARYLAND PKWY
Practice Address - Street 2:SUITE 218
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2441
Practice Address - Country:US
Practice Address - Phone:702-893-0800
Practice Address - Fax:702-893-0109
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2010-12-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NV5908208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2002461Medicaid
NV2002461Medicaid