MEDICARE: ANDREA DAWN WISE AGACNP-BC

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
1	363LA2100X	Acute Care Nurse Practitioner	77871	KS

General Provider Information

NPI Number	:	1417462151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA DAWN WISE AGACNP-BC

Provider Business Mailing Address
First Line	:	1880 KENDRICK LN
Second Line	:
City	:	EL DORADO
State	:	KS
Zip	:	67042-4064
Country	:	US
Telephone Number	:	316-734-0443
Fax Number	:

Provider Business Practice Location Address
First Line	:	1035 N EMPORIA AVE STE 105
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67214-2998
Country	:	US
Telephone Number	:	800-263-3366
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2017
Last Update Date	:	12/10/2024

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