Provider Demographics
NPI:1265779920
Name:WISE, TONY FERNANDO (PASTOR)
Entity type:Individual
Prefix:MR
First Name:TONY
Middle Name:FERNANDO
Last Name:WISE
Suffix:
Gender:M
Credentials:PASTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 NE 68TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-7817
Mailing Address - Country:US
Mailing Address - Phone:405-639-7561
Mailing Address - Fax:
Practice Address - Street 1:1201 NE 68TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-7817
Practice Address - Country:US
Practice Address - Phone:405-639-7561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor