Healthcare Provider Details

I. General information

NPI: 1376408963
Provider Name (Legal Business Name): MICHAEL DARREN WISE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 SPUR 591
AMARILLO TX
79107-9606
US

IV. Provider business mailing address

12000 PERCELL ST
AMARILLO TX
79118-3661
US

V. Phone/Fax

Practice location:
  • Phone: 806-381-7080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1219692
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: