Healthcare Provider Details

I. General information

NPI: 1447833298
Provider Name (Legal Business Name): KENNETH WISE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 STURGIS STREET
TWENTYNINE PALMS CA
92278
US

IV. Provider business mailing address

1145 STURGIS STREET
TWENTYNINE PALMS CA
92277
US

V. Phone/Fax

Practice location:
  • Phone: 410-707-6293
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA203427
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101275874
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: