Basic Information
| Provider Information | |||||||||
| NPI: | 1003229568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISENBAKER | ||||||||
| FirstName: | CHAELI | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON | ||||||||
| OtherFirstName: | CHAELI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3832 DANE LN | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2297403604 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2412 N OAK ST | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316022567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292441400 | ||||||||
| FaxNumber: | 2292445512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2014 | ||||||||
| LastUpdateDate: | 05/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 7207 | 01 | GA | GEORGIA LICENSE | OTHER |