Provider Demographics
NPI:1700949815
Name:WISECUP, TRINA (DO)
Entity Type:Individual
Prefix:DR
First Name:TRINA
Middle Name:
Last Name:WISECUP
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3156 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-2400
Mailing Address - Country:US
Mailing Address - Phone:215-831-1100
Mailing Address - Fax:215-807-8951
Practice Address - Street 1:3156 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-2400
Practice Address - Country:US
Practice Address - Phone:215-831-1100
Practice Address - Fax:215-807-8951
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-008301-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1752064Medicaid
PA026713F5ZMedicare ID - Type Unspecified
PA1752064Medicaid