Healthcare Provider Details

I. General information

NPI: 1932480167
Provider Name (Legal Business Name): ADAM L WISOR CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL AVE
DU BOIS PA
15801-1440
US

IV. Provider business mailing address

100 HOSPITAL AVE
DU BOIS PA
15801-1440
US

V. Phone/Fax

Practice location:
  • Phone: 814-375-3800
  • Fax: 814-375-3886
Mailing address:
  • Phone: 814-375-3800
  • Fax: 814-375-3886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP011466
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: