Healthcare Provider Details

I. General information

NPI: 1447710777
Provider Name (Legal Business Name): ZACHARY CORDELL WISE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8922
  • Fax: 910-907-6069
Mailing address:
  • Phone: 910-907-8922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number12793572-1204
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number12793572-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: