=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902026800
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACI K WISE PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 04/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 HOWELL MILL RD NW SUITE 450
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318-2538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-355-4393
-----------------------------------------------------
Fax | 404-419-9852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 HOWELL MILL NWRD 450
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-355-4393
-----------------------------------------------------
Fax | 404-609-7649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 004739
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------