Provider Demographics
NPI:1689195414
Name:WISE, HEIDI LYNN
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYNN
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:LYNN
Other - Last Name:THRAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3495 BERGMAN PL SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-9384
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 SW 26TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97331-8624
Practice Address - Country:US
Practice Address - Phone:541-737-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-01
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000014912255A2300X
ORPA184479363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer