Provider Demographics
NPI:1104419472
Name:WISE, ELIZABETH ANN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN MARIE
Last Name:WISE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9225 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GODWIN
Mailing Address - State:NC
Mailing Address - Zip Code:28344-8361
Mailing Address - Country:US
Mailing Address - Phone:910-723-1072
Mailing Address - Fax:
Practice Address - Street 1:7118 MAIN ST
Practice Address - Street 2:
Practice Address - City:WADE
Practice Address - State:NC
Practice Address - Zip Code:28395-9749
Practice Address - Country:US
Practice Address - Phone:910-483-6694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001011052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant