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NPI Code Detail

MEDICARE: MR. RUSSELL J WISE FNP

MEDICARE: MR. RUSSELL J WISE FNP
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
1363L00000XNurse Practitioner633018TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1157631602OTHERTXCSHCN
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1750313375
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. RUSSELL J WISE FNP
Provider Business Mailing Address
First Line : 2007 S ZAPATA HWY
Second Line :
City : LAREDO
State : TX
Zip : 78046-6510
Country : US
Telephone Number : 956-795-8101
Fax Number : 956-795-8195
Provider Business Practice Location Address
First Line : 2007 S ZAPATA HWY
Second Line :
City : LAREDO
State : TX
Zip : 78046-6510
Country : US
Telephone Number : 956-795-8101
Fax Number : 956-795-8195
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/06/2006
Last Update Date : 10/30/2012

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