Provider Demographics
NPI:1215929591
Name:WISE, MICHAEL THOMAS (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:WISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756
Mailing Address - Country:US
Mailing Address - Phone:541-548-5089
Mailing Address - Fax:541-504-5353
Practice Address - Street 1:707 SW 9TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2726
Practice Address - Country:US
Practice Address - Phone:541-728-0085
Practice Address - Fax:541-504-5353
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3915111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU80090Medicare UPIN
CT350001306Medicare ID - Type Unspecified