Provider Demographics
NPI:1265177281
Name:WISEMAN, MARK A
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:WISEMAN
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 1:11464 HOGHE RD
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-9225
Mailing Address - Country:US
Mailing Address - Phone:419-203-9284
Mailing Address - Fax:
Practice Address - Street 1:302 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-1048
Practice Address - Country:US
Practice Address - Phone:419-203-9284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant