Healthcare Provider Details

I. General information

NPI: 1780948570
Provider Name (Legal Business Name): TRESA LYNNE WIZE DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 BEANER HOLLOW RD
BEAVER PA
15009-9723
US

IV. Provider business mailing address

1030 BEANER HOLLOW RD
BEAVER PA
15009-9723
US

V. Phone/Fax

Practice location:
  • Phone: 724-775-4242
  • Fax: 724-775-4960
Mailing address:
  • Phone: 724-775-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC006397
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: