Provider Demographics
NPI:1942208939
Name:WISDOM, BEVERLY A (PA)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:A
Last Name:WISDOM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10701 WADE PARK
Mailing Address - Street 2:SUITE 1-B 236
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1702
Mailing Address - Country:US
Mailing Address - Phone:419-215-3171
Mailing Address - Fax:216-231-3411
Practice Address - Street 1:10701 EAST BLVD
Practice Address - Street 2:SUITE 1B 236
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1702
Practice Address - Country:US
Practice Address - Phone:419-215-3171
Practice Address - Fax:216-231-3411
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50001450363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH05073Medicare UPIN
OH75891Medicare PIN
OH970013822Medicare PIN