Basic Information
| Provider Information | |||||||||
| NPI: | 1821689365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | AMOS | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 N IRBY ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295012808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436679414 | ||||||||
| FaxNumber: | 8436679414 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 THURGOOD MARSHALL HWY STE B | ||||||||
| Address2: | |||||||||
| City: | KINGSTREE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295564108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8463555628 | ||||||||
| FaxNumber: | 8433555616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2021 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 24626 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.