Provider Demographics
NPI:1194155325
Name:WISE, THOMAS ALAN (AUD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALAN
Last Name:WISE
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9033 BASELINE RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1255
Mailing Address - Country:US
Mailing Address - Phone:909-989-4800
Mailing Address - Fax:909-989-4883
Practice Address - Street 1:9033 BASELINE RD
Practice Address - Street 2:SUITE F
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1255
Practice Address - Country:US
Practice Address - Phone:909-989-4800
Practice Address - Fax:909-989-4883
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU 2930237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter