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Individual
MR. MICHAEL R WISDOM
Active
Individual
MR. MICHAEL R WISDOM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT000867
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
354809
WELLCARE
GA
01
—
58172018531201A001
TRICARE
GA
01
—
980154
BCBS
GA
Enumeration date
07/31/2006
Last updated
04/20/2008
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