Provider Demographics
NPI:1649221367
Name:WISE WOMAN OB/GYN, PC
Entity Type:Organization
Organization Name:WISE WOMAN OB/GYN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCI
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-782-6262
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:STE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-476-1792
Practice Address - Street 1:172 CLINTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3602
Practice Address - Country:US
Practice Address - Phone:315-782-6262
Practice Address - Fax:315-782-5181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02751077Medicaid
NYDF2175Medicare PIN
NY02751077Medicaid