Healthcare Provider Details

I. General information

NPI: 1750313375
Provider Name (Legal Business Name): RUSSELL J WISE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 S ZAPATA HWY
LAREDO TX
78046-6510
US

IV. Provider business mailing address

2007 S ZAPATA HWY
LAREDO TX
78046-6510
US

V. Phone/Fax

Practice location:
  • Phone: 956-795-8101
  • Fax: 956-795-8195
Mailing address:
  • Phone: 956-795-8101
  • Fax: 956-795-8195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number633018
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: