Basic Information
| Provider Information | |||||||||
| NPI: | 1891088910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISE | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | DAVIS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVIS | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 25487 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342772487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412025342 | ||||||||
| FaxNumber: | 8552534836 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 GOODLETTE-FRANK RD N STE 100 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393512990 | ||||||||
| FaxNumber: | 2393004128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2011 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | ME120329 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | 16178 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | ME120329 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 012206800 | 05 | FL | MEDICAID | HV151Y | 01 | FL | MEDICARE | OTHER | 14W2L | 01 | FL | BCBS | OTHER |