Healthcare Provider Details

I. General information

NPI: 1730671009
Provider Name (Legal Business Name): DAVID WISE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2018
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 30TH ST STE 215
BOULDER CO
80301-1087
US

IV. Provider business mailing address

56 S HAZEL CT
DENVER CO
80219-2023
US

V. Phone/Fax

Practice location:
  • Phone: 303-546-9201
  • Fax:
Mailing address:
  • Phone: 406-396-1723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0018972
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: