Provider Demographics
NPI:1306246558
Name:WISSE, AMY OSGUTHORPE
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:OSGUTHORPE
Last Name:WISSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:OSGUTHORPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8908
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18860363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2900Medicaid
SCP01413233OtherRR MEDICARE
SCSC43285277Medicare PIN
SCNP2900Medicaid
SCSC43288798Medicare PIN
SCSC43287498Medicare PIN
SCSC43287126Medicare UPIN
SCP01413233OtherRR MEDICARE
SCSC43286834Medicare PIN
SCSC43287522Medicare PIN
SCSC43287819Medicare PIN
SCSC43286882Medicare PIN
SCSC43287006Medicare PIN
SCSC43285282Medicare PIN
SCSC43286868Medicare PIN
SCSC43285281Medicare PIN