Provider Demographics
NPI:1033404959
Name:WISEMAN, JASON T (MD, MSPH)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:T
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:MD, MSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PROVIDER ENROLLMENT 41 MALL ROAD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2155
Practice Address - Country:US
Practice Address - Phone:602-406-8222
Practice Address - Fax:602-604-4722
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ618112086X0206X
MA10155262086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology