Provider Demographics
NPI:1053715771
Name:WISE, BRIAN JAMES (LMP)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JAMES
Last Name:WISE
Suffix:
Gender:M
Credentials:LMP
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Mailing Address - Street 1:1855 TROSSACHS BLVD SE
Mailing Address - Street 2:2704
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-5946
Mailing Address - Country:US
Mailing Address - Phone:425-241-2638
Mailing Address - Fax:
Practice Address - Street 1:1611 116TH AVE NE
Practice Address - Street 2:200
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3045
Practice Address - Country:US
Practice Address - Phone:425-455-0088
Practice Address - Fax:425-455-0340
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMA60503846225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist