Healthcare Provider Details

I. General information

NPI: 1346604675
Provider Name (Legal Business Name): SAMANTHA KATHERINE WISEMAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 7TH AVE
LONGVIEW WA
98632-3166
US

IV. Provider business mailing address

1230 7TH AVE
LONGVIEW WA
98632-3166
US

V. Phone/Fax

Practice location:
  • Phone: 503-813-2000
  • Fax: 360-636-6282
Mailing address:
  • Phone: 503-813-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberOP61184388
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP61184388
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: