Provider Demographics
NPI:1134980113
Name:WISE, CHLOE (PA-C)
Entity type:Individual
Prefix:
First Name:CHLOE
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 1/2 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3113
Mailing Address - Country:US
Mailing Address - Phone:330-842-3283
Mailing Address - Fax:
Practice Address - Street 1:1108 VESTER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-1302
Practice Address - Country:US
Practice Address - Phone:937-399-7100
Practice Address - Fax:937-399-7355
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.008551RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant