Provider Demographics
NPI:1386802098
Name:WOLFGANG, ALISE (CRNP-BC)
Entity type:Individual
Prefix:
First Name:ALISE
Middle Name:
Last Name:WOLFGANG
Suffix:
Gender:F
Credentials:CRNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WALNUT ST
Mailing Address - Street 2:5TH FLOOR MOB
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5563
Mailing Address - Country:US
Mailing Address - Phone:215-503-7326
Mailing Address - Fax:215-503-7577
Practice Address - Street 1:1100 WALNUT ST
Practice Address - Street 2:5TH FLOOR MOB
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5563
Practice Address - Country:US
Practice Address - Phone:215-503-7326
Practice Address - Fax:215-503-7577
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009379363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA128818Medicare PIN