Provider Demographics
NPI:1588601546
Name:WISE, ELLEN S (PAC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:S
Last Name:WISE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4150
Practice Address - Street 1:3130 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-440-4600
Practice Address - Fax:937-619-4150
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P28542Medicare UPIN
OHMIPA16943Medicare PIN
OHPA16946Medicare PIN
OHPA16945Medicare PIN
OHMIPA16942Medicare PIN