Provider Demographics
NPI:1619078136
Name:WISE, ELIZABETH A (DO)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:A
Last Name:WISE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6220 LAKESHORE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505
Mailing Address - Country:US
Mailing Address - Phone:814-835-2133
Mailing Address - Fax:814-452-4174
Practice Address - Street 1:2315 MYRTLE ST STE 220
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-4609
Practice Address - Country:US
Practice Address - Phone:814-454-8185
Practice Address - Fax:814-454-3894
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012107207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01900579Medicaid
H65940Medicare UPIN
PA01900579Medicaid