Provider Demographics
NPI:1215463161
Name:WISE, AMANDA TUYET-ANH (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:TUYET-ANH
Last Name:WISE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:TUYET-ANH
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5161 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7707
Mailing Address - Country:US
Mailing Address - Phone:214-648-4898
Mailing Address - Fax:
Practice Address - Street 1:5161 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7707
Practice Address - Country:US
Practice Address - Phone:214-648-4898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX667387207R00000X
WAOL60865446208100000X
UT12925107-12042081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOL60865446OtherMEDICAL LICENSE NUMBER