Healthcare Provider Details

I. General information

NPI: 1548955198
Provider Name (Legal Business Name): CARTER REESE WISDOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 E DOWNING ST
TAHLEQUAH OK
74464-3014
US

IV. Provider business mailing address

32090 E 747 RD
WAGONER OK
74467-9446
US

V. Phone/Fax

Practice location:
  • Phone: 918-960-7852
  • Fax:
Mailing address:
  • Phone: 918-348-1439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: