Healthcare Provider Details

I. General information

NPI: 1346613437
Provider Name (Legal Business Name): JONATHAN BIRCHLER WISE DPT, PT, MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 AMERICAN BLVD W # 200
BLOOMINGTON MN
55431-4420
US

IV. Provider business mailing address

13643 BRICK PATH
ROSEMOUNT MN
55068-2471
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax:
Mailing address:
  • Phone: 608-963-9526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002462A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number12745
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: