Healthcare Provider Details

I. General information

NPI: 1306987920
Provider Name (Legal Business Name): DAVID WISEMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CLINIC DR
TARBORO NC
27886-1935
US

IV. Provider business mailing address

101 CLINIC DR
TARBORO NC
27886-1935
US

V. Phone/Fax

Practice location:
  • Phone: 252-823-2105
  • Fax: 252-824-7653
Mailing address:
  • Phone: 252-823-2105
  • Fax: 252-824-7653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102519
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: