Healthcare Provider Details

I. General information

NPI: 1265015572
Provider Name (Legal Business Name): DALTON ANDREW WISE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 04/22/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CARSON ST
TORRANCE CA
90502-2059
US

IV. Provider business mailing address

2403 LOUISIANA ST
LITTLE ROCK AR
72206-2239
US

V. Phone/Fax

Practice location:
  • Phone: 424-306-6219
  • Fax:
Mailing address:
  • Phone: 501-580-2291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberMD2024-1078
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: