Basic Information
| Provider Information | |||||||||
| NPI: | 1346891942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISOWATY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 MACK BLVD FL 4 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181035622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2597 SCHOENERSVILLE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180177325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104028900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2019 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9112585 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA061947 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.