Provider Demographics
NPI:1902026800
Name:WISE, STACI K (PA)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:K
Last Name:WISE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1800 HOWELL MILL NWRD 450
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2508
Mailing Address - Country:US
Mailing Address - Phone:404-355-4393
Mailing Address - Fax:404-609-7649
Practice Address - Street 1:1800 HOWELL MILL RD NW
Practice Address - Street 2:SUITE 450
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-2538
Practice Address - Country:US
Practice Address - Phone:404-355-4393
Practice Address - Fax:404-419-9852
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA004739207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism