Provider Demographics
NPI:1215980800
Name:WRISTON, NAOMI FAYE (DO)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:FAYE
Last Name:WRISTON
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:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-0550
Mailing Address - Country:US
Mailing Address - Phone:740-687-5164
Mailing Address - Fax:740-654-1417
Practice Address - Street 1:6760 A AVERY-MUIRFIELD DRIVE
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017
Practice Address - Country:US
Practice Address - Phone:614-791-9952
Practice Address - Fax:614-791-9953
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002932207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0410700Medicaid
WR0467014Medicare ID - Type Unspecified
OH0410700Medicaid