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General NPI Number Information
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NPI Number | 1578426441
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Entity Type | Individual
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Provider Name | WILMOT R GISSENDANNER IV
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Gender | Male
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Dates
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Enumeration Date | 12/06/2025
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Last Update Date | 12/06/2025
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Provider Practice Location Address
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Address Line | 3000 SAINT MATTHEWS RD
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City | ORANGEBURG
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State | SC
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Zip | 29118-1442
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Country | US
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Telephone | 803-395-2871
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 23321
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City | NEW YORK
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State | NY
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Zip | 10087-3321
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State | SC
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