MEDICARE: ASHLYN CHERIE WISBAUER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	2506	OK

General Provider Information

NPI Number	:	1932813623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLYN CHERIE WISBAUER

Provider Business Mailing Address
First Line	:	14715 BRISTOL PARK BLVD
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73013-1894
Country	:	US
Telephone Number	:	405-840-1686
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 S SOONER RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73110-2425
Country	:	US
Telephone Number	:	405-610-1909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2023
Last Update Date	:	01/09/2023

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