Provider Demographics
NPI:1982683488
Name:WISE, DEENA RENAE (DO)
Entity Type:Individual
Prefix:DR
First Name:DEENA
Middle Name:RENAE
Last Name:WISE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DEENA
Other - Middle Name:RENAE
Other - Last Name:WALDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2502 W ELK AVE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1562
Practice Address - Country:US
Practice Address - Phone:580-252-9600
Practice Address - Fax:580-252-6100
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15511208000000X, 208M00000X
MO2002008852208000000X
OK3820208000000X
NC2020-03433208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100877500Medicaid
OKOK400892Medicare PIN
H57860Medicare UPIN