Provider Demographics
NPI:1891559977
Name:WISE, NATHANIEL P (DPT)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:P
Last Name:WISE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 SUNNYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-3467
Mailing Address - Country:US
Mailing Address - Phone:423-578-4643
Mailing Address - Fax:
Practice Address - Street 1:420 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2504
Practice Address - Country:US
Practice Address - Phone:423-297-1813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15442225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist