Provider Demographics
NPI:1114402344
Name:WISEMAN, TAYLOR (PA-C)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 CHAMPION GRANDVIEW WAY APT 7103
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-8288
Mailing Address - Country:US
Mailing Address - Phone:281-919-3822
Mailing Address - Fax:
Practice Address - Street 1:1600 W 38TH ST STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6405
Practice Address - Country:US
Practice Address - Phone:512-324-3580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12257363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant