MEDICARE: WISH MEMA

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	302R00000X	Health Maintenance Organization	742276	TX

General Provider Information

NPI Number	:	1851721518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISH MEMA

Provider Business Mailing Address
First Line	:	1433 WIND DANCER TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76131-5416
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1433 WIND DANCER TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76131-5416
Country	:	US
Telephone Number	:	469-223-9489
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	WISH MEMA
Credential	:	ACNP
Telephone Number	:	469-223-9489

Provider Enumeration Date	:	11/17/2013
Last Update Date	:	11/17/2013

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