Provider Demographics
NPI:1609309533
Name:WISE, LOLA MUDGISTRATOVA (MD)
Entity type:Individual
Prefix:
First Name:LOLA
Middle Name:MUDGISTRATOVA
Last Name:WISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 104TH PL SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-4538
Mailing Address - Country:US
Mailing Address - Phone:206-661-2563
Mailing Address - Fax:
Practice Address - Street 1:400 S 43RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5714
Practice Address - Country:US
Practice Address - Phone:206-661-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60963016207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine