Healthcare Provider Details

I. General information

NPI: 1003747692
Provider Name (Legal Business Name): MICHAEL WISEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CHRISTOPHER LN
CLINTON CT
06413-1830
US

IV. Provider business mailing address

4 CHRISTOPHER LN
CLINTON CT
06413-1830
US

V. Phone/Fax

Practice location:
  • Phone: 203-200-8537
  • Fax:
Mailing address:
  • Phone: 203-200-8537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12.017450
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: