Provider Demographics
NPI:1073756045
Name:WISMANN, ANDREA E (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:E
Last Name:WISMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 NE 13TH ST # 1200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-8558
Mailing Address - Fax:405-271-3887
Practice Address - Street 1:1122 NE 13TH ST # 1200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1039
Practice Address - Country:US
Practice Address - Phone:405-271-8558
Practice Address - Fax:405-271-3887
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0051260207Q00000X
OK39061207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine