| Doctor Name: | TARA E WISE |
| NPI Number: | 1851675219 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | M.S., O.T.R./L |
| License Number: | 016540-1 |
| Business Practice Address: | 11050 Mount Belvedere Blvd Fort Drum, NY - 136025438 |
| Business Phone Number: | 3157723380 |
| Business Fax Number: | |
| Mailing Address: | 11050 Mount Belvedere Blvd, FORT DRUM |
| State: | NY |
| Postal Code: | 136025438 |
| Phone Number: | 3157723380 |
| Fax Number: | |
| NPI Enumeration Date: | 10/04/2011 |
| NPI Last Update Date: | 10/04/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171000000X |
| License Number: | 016540-1 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Military Health Care Provider |
| Taxonomy Specialization: | |
| Taxonomy Definition: | Active duty military health care providers not otherwise classified who need to be separately identified for operational, clinical, or administrative processes. |