Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT010877L | PA |
NPI | 1003241662 |
---|---|
Provider Name | Tara Lynn Wise |
First Address | Mount Carmel, PA 17851-1427 |
Second Address | Mount Carmel, PA 17851-1427 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2013 |
Last Update Date | 13/09/2013 |