Provider Demographics
NPI:1306987920
Name:WISEMAN, DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:M
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 1:201 COX BLVD
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9479
Mailing Address - Country:US
Mailing Address - Phone:919-735-7580
Mailing Address - Fax:919-580-9338
Practice Address - Street 1:201 COX BLVD
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9479
Practice Address - Country:US
Practice Address - Phone:919-735-7580
Practice Address - Fax:919-580-9338
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102519174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89130F0Medicaid
NC136YAOtherBCBS
NCS63098Medicare UPIN
NC136YAOtherBCBS