Provider Demographics
NPI:1518323328
Name:WISE, CLAIRE THERESA (PA)
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:THERESA
Last Name:WISE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CLAIRE
Other - Middle Name:THERESA
Other - Last Name:MCCGUIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:256 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1947
Mailing Address - Country:US
Mailing Address - Phone:716-677-4469
Mailing Address - Fax:716-677-4470
Practice Address - Street 1:ELM AND CARLTON STREETS
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:716-845-3483
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-08
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018949363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB0832Medicare UPIN