Provider Demographics
NPI:1710494869
Name:WISEMAN, SHAWN MICHAEL (ATC)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:MICHAEL
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 HORSLEY DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 ATHLETIC CENTER DR
Practice Address - Street 2:
Practice Address - City:HAMPDEN SYDNEY D
Practice Address - State:VA
Practice Address - Zip Code:23943-2394
Practice Address - Country:US
Practice Address - Phone:434-223-6843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260022082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer