Healthcare Provider Details

I. General information

NPI: 1083896534
Provider Name (Legal Business Name): SEAN ROBERT WISE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 ARMY PENTAGON
WASHINGTON DC
20310-5801
US

IV. Provider business mailing address

5801 ARMY PENTAGON
WASHINGTON DC
20310-5801
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-9619
  • Fax:
Mailing address:
  • Phone: 910-907-9619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101284669
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: