Provider Demographics
NPI:1952400459
Name:WISE, MARLENE MARGARET (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:MARGARET
Last Name:WISE
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 1:20826 ROUTE 19
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-6019
Mailing Address - Country:US
Mailing Address - Phone:724-776-4776
Mailing Address - Fax:724-776-0251
Practice Address - Street 1:20826 ROUTE 19
Practice Address - Street 2:
Practice Address - City:CRANBERRY TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:16066-6019
Practice Address - Country:US
Practice Address - Phone:724-776-4776
Practice Address - Fax:724-776-0251
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051484363AM0700X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA325132Medicare PIN