Provider Demographics
NPI:1952346678
Name:WISEMAN, AMBER J (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:J
Last Name:WISEMAN
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:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:MC INTOSH
Mailing Address - State:SD
Mailing Address - Zip Code:57641-0195
Mailing Address - Country:US
Mailing Address - Phone:605-273-4335
Mailing Address - Fax:605-273-4360
Practice Address - Street 1:208 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MCINTOSH
Practice Address - State:SD
Practice Address - Zip Code:57641-0195
Practice Address - Country:US
Practice Address - Phone:605-273-4335
Practice Address - Fax:605-273-4360
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q37737Medicare UPIN