Provider Demographics
NPI:1114217320
Name:WISE, BRENT THOMAS (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:THOMAS
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-8500
Mailing Address - Country:US
Mailing Address - Phone:913-588-5000
Mailing Address - Fax:
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160
Practice Address - Country:US
Practice Address - Phone:913-588-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-10
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA77991207X00000X
KS04-42091207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery