Provider Demographics
NPI:1598195042
Name:WISEMAN FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:WISEMAN FAMILY PRACTICE PLLC
Other - Org Name:WISEMAN FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-345-8970
Mailing Address - Street 1:2500 S LAKELINE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2967
Mailing Address - Country:US
Mailing Address - Phone:512-345-8970
Mailing Address - Fax:512-345-6689
Practice Address - Street 1:2500 S LAKELINE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2967
Practice Address - Country:US
Practice Address - Phone:512-345-8970
Practice Address - Fax:512-345-6689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9746207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1114188497OtherNPI