Healthcare Provider Details

I. General information

NPI: 1942121496
Provider Name (Legal Business Name): MACY LAUREN WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 N LAMAR BLVD STE 155
AUSTIN TX
78756-0002
US

IV. Provider business mailing address

3800 N LAMAR BLVD STE 155
AUSTIN TX
78756-0002
US

V. Phone/Fax

Practice location:
  • Phone: 512-617-9200
  • Fax: 512-666-3765
Mailing address:
  • Phone: 512-617-9200
  • Fax: 512-666-3765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1023000
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: