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NPI Code Detail

MEDICARE: JACLYN WISE PA-C

MEDICARE: JACLYN WISE PA-C
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 Assistant0010-11679NC
2363A00000XPhysician AssistantPA9120414FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1972806339
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACLYN WISE PA-C
Provider Business Mailing Address
First Line : 953 TIDALWALK DR
Second Line :
City : WILMINGTON
State : NC
Zip : 28409-4968
Country : US
Telephone Number : 239-738-4935
Fax Number :
Provider Business Practice Location Address
First Line : 9617 GULF RESEARCH LN
Second Line :
City : FORT MYERS
State : FL
Zip : 33912-4560
Country : US
Telephone Number : 239-418-0999
Fax Number : 239-418-0091
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/07/2010
Last Update Date : 01/28/2026

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Directions to “ JACLYN WISE PA-C” Practice Location

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