Provider Demographics
NPI:1881715746
Name:WISE, CRISTIN LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:CRISTIN
Middle Name:LOUISE
Last Name:WISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 CENTREVILLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-3289
Mailing Address - Country:US
Mailing Address - Phone:703-481-8600
Mailing Address - Fax:
Practice Address - Street 1:3914 CENTREVILLE RD STE 101
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3289
Practice Address - Country:US
Practice Address - Phone:703-481-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01121208000000X
GARTP001917208000000X
VA0101251377208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics