Provider Demographics
NPI:1255724316
Name:WISEMAN, AMY KATHRYN (PTA, MS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KATHRYN
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:PTA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3994 DUNBARTON WAY NE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2002
Mailing Address - Country:US
Mailing Address - Phone:404-358-4762
Mailing Address - Fax:
Practice Address - Street 1:8480 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30350-2800
Practice Address - Country:US
Practice Address - Phone:678-461-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003395225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant