Healthcare Provider Details

I. General information

NPI: 1477780567
Provider Name (Legal Business Name): DR RICHARD J WISEMAN PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S. LAKELINE BLVD. STE. 100
CEDAR PARK TX
78613-2968
US

IV. Provider business mailing address

2500 S. LAKELINE BLVD. STE. 100
CEDAR PARK TX
78613-2968
US

V. Phone/Fax

Practice location:
  • Phone: 512-345-8970
  • Fax: 512-345-6689
Mailing address:
  • Phone: 512-345-8970
  • Fax: 512-345-6689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF0084
License Number StateTX

VIII. Authorized Official

Name: MRS. LAURA C COPELAND
Title or Position: BILLING/INSURANCE MANAGER
Credential:
Phone: 512-345-8970