Healthcare Provider Details

I. General information

NPI: 1679060818
Provider Name (Legal Business Name): BRADLEY WILLIAM WISE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 E 9TH AVE STE 120
DENVER CO
80220-3902
US

IV. Provider business mailing address

4545 E 9TH AVE STE 120
DENVER CO
80220-3902
US

V. Phone/Fax

Practice location:
  • Phone: 303-388-2922
  • Fax: 303-388-2962
Mailing address:
  • Phone: 303-388-2922
  • Fax: 303-388-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDR.0063626
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: