Provider Demographics
NPI:1932416617
Name:WISE, GINA D
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:D
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 YORKTOWN DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1568
Mailing Address - Country:US
Mailing Address - Phone:770-460-2331
Mailing Address - Fax:770-460-2099
Practice Address - Street 1:101 YORKTOWN DR
Practice Address - Street 2:SUITE 225
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1568
Practice Address - Country:US
Practice Address - Phone:770-460-2331
Practice Address - Fax:770-460-2099
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO000890156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician