Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | OP61184388 | WA |
Y | 207Q00000X | Family Doctor | OP61184388 | WA |
NPI | 1346604675 |
---|---|
Provider Name | Dr. Samantha Katherine Wiseman |
First Address | Longview, WA 98632-3166 |
Second Address | Longview, WA 98632-3166 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2016 |
Last Update Date | 02/12/2021 |