Provider Demographics
NPI:1003229568
Name:WISENBAKER, CHAELI (PA-C)
Entity Type:Individual
Prefix:
First Name:CHAELI
Middle Name:
Last Name:WISENBAKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHAELI
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3832 DANE LN
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601
Mailing Address - Country:US
Mailing Address - Phone:229-740-3604
Mailing Address - Fax:
Practice Address - Street 1:2412 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2567
Practice Address - Country:US
Practice Address - Phone:229-244-1400
Practice Address - Fax:229-244-5512
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7207OtherGEORGIA LICENSE