Provider Demographics
NPI:1740467794
Name:WISE, LAUREN HOBART (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:HOBART
Last Name:WISE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:LEAH
Other - Last Name:HOBART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 2447
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35403-2447
Mailing Address - Country:US
Mailing Address - Phone:205-345-0192
Mailing Address - Fax:205-247-2194
Practice Address - Street 1:305 PAUL BRYANT DRIVE E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35403-2055
Practice Address - Country:US
Practice Address - Phone:205-345-0192
Practice Address - Fax:205-247-2194
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-573363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051060244OtherBLUE CROSS BLUE SHIELD
AL051060244OtherBLUE CROSS BLUE SHIELD