Provider Demographics
NPI:1912570607
Name:WISDOM, JERRY PAUL III (CRNP)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:PAUL
Last Name:WISDOM
Suffix:III
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 ROSS CLARK CIR STE 400
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-4770
Mailing Address - Country:US
Mailing Address - Phone:334-305-0400
Mailing Address - Fax:
Practice Address - Street 1:1450 ROSS CLARK CIR STE 400
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-4770
Practice Address - Country:US
Practice Address - Phone:334-305-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-152894363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily