Provider Demographics
NPI:1871947127
Name:WISE, WILLARD WADE III (CRNA)
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:WADE
Last Name:WISE
Suffix:III
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:TREY
Other - Middle Name:W
Other - Last Name:WISE
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:7822 DAVENPORT ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3629
Mailing Address - Country:US
Mailing Address - Phone:402-391-4855
Mailing Address - Fax:402-391-6818
Practice Address - Street 1:7822 DAVENPORT ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3629
Practice Address - Country:US
Practice Address - Phone:402-391-4855
Practice Address - Fax:402-391-6818
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101342367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered