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NPI Code Detail

MEDICARE: BEVERLY A WISDOM PA

MEDICARE: BEVERLY A WISDOM PA
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
1363AM0700XMedical Physician Assistant50001450OH

General Provider Information

NPI Number : 1942208939
Entity Type Code : Individual
Provider Name (Legal Business Name) : BEVERLY A WISDOM PA
Provider Business Mailing Address
First Line : 10701 WADE PARK
Second Line : SUITE 1-B 236
City : CLEVELAND
State : OH
Zip : 44106-1702
Country : US
Telephone Number : 419-215-3171
Fax Number : 216-231-3411
Provider Business Practice Location Address
First Line : 10701 EAST BLVD
Second Line : SUITE 1B 236
City : CLEVELAND
State : OH
Zip : 44106-1702
Country : US
Telephone Number : 419-215-3171
Fax Number : 216-231-3411
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/13/2005
Last Update Date : 06/29/2020

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Directions to “ BEVERLY A WISDOM PA” Practice Location

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