Provider Demographics
NPI:1225018831
Name:WISE, MATHEW LEIGHTON (MPT)
Entity type:Individual
Prefix:MR
First Name:MATHEW
Middle Name:LEIGHTON
Last Name:WISE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 E AJO WAY STE 149
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-6269
Mailing Address - Country:US
Mailing Address - Phone:520-325-4002
Mailing Address - Fax:
Practice Address - Street 1:1991 E AJO WAY STE 149
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-6269
Practice Address - Country:US
Practice Address - Phone:520-325-4002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-0121552251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic