Provider Demographics
NPI:1487767117
Name:WISDOM, ROBERT ANTHONY (CRNP)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ANTHONY
Last Name:WISDOM
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3208
Mailing Address - Country:US
Mailing Address - Phone:917-362-6997
Mailing Address - Fax:
Practice Address - Street 1:4444 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3208
Practice Address - Country:US
Practice Address - Phone:917-362-6997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350263363LN0000X, 363LN0000X
IL209014169363LN0000X
FL942926-6363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal