Provider Demographics
NPI:1174816516
Name:WISEHART, TROY A (PA)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:A
Last Name:WISEHART
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 N SENATE BLVD
Practice Address - Street 2:STE 755
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1228
Practice Address - Country:US
Practice Address - Phone:317-962-9186
Practice Address - Fax:317-962-6259
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN5260-0628146N00000X
IN10001291A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400052098Medicare PIN
INP01132136Medicare PIN