Provider Demographics
NPI:1942655097
Name:WISE, AUSTIN JACOB (DO)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JACOB
Last Name:WISE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 MADISON AVE STE 447
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3438
Mailing Address - Country:US
Mailing Address - Phone:901-448-5814
Mailing Address - Fax:
Practice Address - Street 1:920 MADISON AVE STE 447
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3438
Practice Address - Country:US
Practice Address - Phone:901-448-5814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3655207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine