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NPI Code Detail

MEDICARE: BLAKELY DAVID WISE PA

MEDICARE: BLAKELY DAVID WISE PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant0010-08866NC

General Provider Information

NPI Number : 1396201935
Entity Type Code : Individual
Provider Name (Legal Business Name) : BLAKELY DAVID WISE PA
Provider Business Mailing Address
First Line : PO BOX 19305
Second Line :
City : CHARLOTTE
State : NC
Zip : 28219-9305
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 20036 ZION AVE
Second Line : STE 100
City : CORNELIUS
State : NC
Zip : 28031-8435
Country : US
Telephone Number : 704-801-7400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/19/2019
Last Update Date : 09/25/2025

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