Individual
JESSICA WISE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
320 RACETRACK RD NW STE 100B, FORT WALTON BEACH, FL 32547-1796
(850) 374-9610
(850) 374-9611
Mailing address
320 RACETRACK RD NW STE 100B, FORT WALTON BEACH, FL 32547-1796
(850) 374-9610
(850) 374-9611
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
158015
FL
2086S0102X
Surgical Critical Care Physician
Primary
158015
FL
2086S0127X
Trauma Surgery Physician
158015
FL
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1336594050
—
NV
Enumeration date
05/01/2016
Last updated
07/26/2022
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