Provider Demographics
NPI:1972713337
Name:WISDOM, MARISSA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:ANN
Last Name:WISDOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4530
Mailing Address - Country:US
Mailing Address - Phone:701-530-6000
Mailing Address - Fax:701-530-6422
Practice Address - Street 1:401 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4530
Practice Address - Country:US
Practice Address - Phone:701-530-6000
Practice Address - Fax:701-530-6422
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND11239207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1972713337OtherBCBS PROVIDER #
ND11122Medicaid
ND1972713337OtherBCBS PROVIDER #