Provider Demographics
NPI:1114121936
Name:WISE, ROXOLANA LESYA (PA)
Entity Type:Individual
Prefix:MRS
First Name:ROXOLANA
Middle Name:LESYA
Last Name:WISE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:ROXANN
Other - Middle Name:
Other - Last Name:STACHIW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2415 MUSGROVE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-5202
Mailing Address - Country:US
Mailing Address - Phone:301-989-2300
Mailing Address - Fax:301-236-5357
Practice Address - Street 1:2415 MUSGROVE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-5202
Practice Address - Country:US
Practice Address - Phone:301-989-2300
Practice Address - Fax:301-236-5357
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCF 2572363LF0000X
MDPA75548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN