Healthcare Provider Details

I. General information

NPI: 1851077614
Provider Name (Legal Business Name): JESSICA WISEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 MUNICIPAL WAY
EDGEWOOD NM
87015
US

IV. Provider business mailing address

PO BOX 2033
EDGEWOOD NM
87015-2033
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-3406
  • Fax:
Mailing address:
  • Phone: 505-414-0251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: