Provider Demographics
NPI:1679671069
Name:WISMER, CHRISTINE F (PT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:F
Last Name:WISMER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 DOMINGO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-8256
Mailing Address - Country:US
Mailing Address - Phone:505-231-3361
Mailing Address - Fax:
Practice Address - Street 1:230 S SAINT FRANCIS DR
Practice Address - Street 2:#5
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2454
Practice Address - Country:US
Practice Address - Phone:505-982-8561
Practice Address - Fax:505-989-1740
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1265225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20578521Medicaid
NM20578521Medicaid