Provider Demographics
NPI:1821667668
Name:WISENER, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:WISENER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 LIBERTY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-1263
Mailing Address - Country:US
Mailing Address - Phone:412-291-0873
Mailing Address - Fax:
Practice Address - Street 1:UPMC HAMOT SCHOOL OF ANESTHESIA 201 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0001
Practice Address - Country:US
Practice Address - Phone:412-291-0873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN697386163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse