Provider Demographics
NPI:1669103008
Name:WISE, ROBERT A
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:WISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 GARRISON RD
Mailing Address - Street 2:
Mailing Address - City:ENON
Mailing Address - State:OH
Mailing Address - Zip Code:45323-9723
Mailing Address - Country:US
Mailing Address - Phone:937-360-7921
Mailing Address - Fax:
Practice Address - Street 1:5925 GARRISON RD
Practice Address - Street 2:
Practice Address - City:ENON
Practice Address - State:OH
Practice Address - Zip Code:45323-9723
Practice Address - Country:US
Practice Address - Phone:937-360-7921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant