Provider Demographics
NPI:1073502092
Name:WISE, VON P (DC)
Entity Type:Individual
Prefix:DR
First Name:VON
Middle Name:P
Last Name:WISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-1243
Mailing Address - Country:US
Mailing Address - Phone:570-748-7462
Mailing Address - Fax:570-748-8910
Practice Address - Street 1:5 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-1243
Practice Address - Country:US
Practice Address - Phone:570-748-7462
Practice Address - Fax:570-748-8910
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005339L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014136130003Medicaid
PA14952OtherGEISINGER
PA806022OtherFIRST PRIORITY
PA806022OtherFIRST PRIORITY
U45126Medicare UPIN