Provider Demographics
NPI:1144769332
Name:WISEMAN, COURTNEY (PA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1246
Mailing Address - Fax:704-384-6072
Practice Address - Street 1:18144 SECO ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:CA
Practice Address - Zip Code:95327-9498
Practice Address - Country:US
Practice Address - Phone:209-984-4820
Practice Address - Fax:209-984-4825
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07098363A00000X
CA57620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant