MEDICARE: KIMBERLY R WISECUP D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	OS019367	PA
2	2080N0001X	Neonatal-Perinatal Medicine Physician	DO3189	NV

General Provider Information

NPI Number	:	1720469729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY R WISECUP D.O.

Provider Business Mailing Address
First Line	:	3186 S MARYLAND PKWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-2306
Country	:	US
Telephone Number	:	801-915-0546
Fax Number	:

Provider Business Practice Location Address
First Line	:	3186 S MARYLAND PKWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-2306
Country	:	US
Telephone Number	:	702-961-5000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2015
Last Update Date	:	06/29/2022

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Directions to “ KIMBERLY R WISECUP D.O.” Practice Location

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