Provider Demographics
NPI:1669059226
Name:WISEMAN, BRIAN PATRICK
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:PATRICK
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 1:14900 CUMBERLAND GAP RD
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:VA
Mailing Address - Zip Code:24127-7749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 ARBOR DR STE 103
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6585
Practice Address - Country:US
Practice Address - Phone:540-443-3428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-28
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002428224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty