Provider Demographics
NPI:1518097757
Name:WIZBA, ALBERT JAMES (LAC)
Entity Type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:JAMES
Last Name:WIZBA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3742 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SHADYSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:43947-1307
Mailing Address - Country:US
Mailing Address - Phone:740-676-4576
Mailing Address - Fax:
Practice Address - Street 1:3742 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SHADYSIDE
Practice Address - State:OH
Practice Address - Zip Code:43947-1307
Practice Address - Country:US
Practice Address - Phone:740-676-4576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH65.000065171100000X
WV96165171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist