Provider Demographics
NPI:1952303018
Name:WISE, ANDREW E (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:E
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 FULLER CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-2540
Mailing Address - Country:US
Mailing Address - Phone:703-922-5577
Mailing Address - Fax:703-971-9834
Practice Address - Street 1:6160 FULLER CT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-2540
Practice Address - Country:US
Practice Address - Phone:703-922-5577
Practice Address - Fax:703-971-9834
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
627476F61Medicare PIN
E56998Medicare UPIN