Provider Demographics
NPI:1689049355
Name:WISEMAN, PATSY (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:PATSY
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 E QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5637
Mailing Address - Country:US
Mailing Address - Phone:918-261-4439
Mailing Address - Fax:877-992-9262
Practice Address - Street 1:1252 E QUINCY ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5637
Practice Address - Country:US
Practice Address - Phone:918-261-4439
Practice Address - Fax:877-992-9262
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58539163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200673190Medicaid