Provider Demographics
NPI:1447710777
Name:WISE, ZACHARY CORDELL (DO)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:CORDELL
Last Name:WISE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2661 W 3400 S
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-8066
Mailing Address - Country:US
Mailing Address - Phone:256-497-2244
Mailing Address - Fax:
Practice Address - Street 1:7321 BALMER ST BLDG 570
Practice Address - Street 2:
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-586-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12793572-1204171000000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider