MEDICARE: NICHOLE WISE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	10003027A	IN
2	363A00000X	Physician Assistant		IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	068010654	OTHER	IN	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	Q00242769	OTHER	IN	RAILROAD PTAN

General Provider Information

NPI Number	:	1225654189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE WISE PA-C

Provider Business Mailing Address
First Line	:	430 INDIANA AVE APT 317
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-3242
Country	:	US
Telephone Number	:	574-344-9020
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 UNIVERSITY BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-5149
Country	:	US
Telephone Number	:	574-344-9020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2020
Last Update Date	:	03/03/2026

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Directions to “ NICHOLE WISE PA-C” Practice Location

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