Provider Demographics
NPI:1336155365
Name:WISE, SCOTT ALLAN
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALLAN
Last Name:WISE
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 1:46 ROSEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-4550
Mailing Address - Country:US
Mailing Address - Phone:724-458-9473
Mailing Address - Fax:724-458-6378
Practice Address - Street 1:121 CRANBERRY RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-4629
Practice Address - Country:US
Practice Address - Phone:724-458-9473
Practice Address - Fax:724-458-1626
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008218L225100000X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA627418Medicare ID - Type Unspecified