Basic Information
| Provider Information | |||||||||
| NPI: | 1003994096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISER | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1903 W MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490085200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693873290 | ||||||||
| FaxNumber: | 2693872944 | ||||||||
| Practice Location | |||||||||
| Address1: | 1903 W MICHIGAN AVE | ||||||||
| Address2: | SINDECUSE HEALTH CENTER, WESTERN MICHIGAN UNIVERSITY | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490085200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693873287 | ||||||||
| FaxNumber: | 2693872944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 12/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 5601002257 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0853911050 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 0C94735 | 01 | BCBS GROUP | OTHER |