Individual
MR. PAUL PENCE WISMAN JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1011 E JEFFERSON ST, CHARLOTTESVILLE, VA 22902-5354
(434) 296-9161
(434) 296-1036
Mailing address
104 KERRY LN, CHARLOTTESVILLE, VA 22901-2925
(434) 973-3806
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
0101049022
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
006725856
—
VA
01
—
010724
CIGNA
VA
01
—
12211500001
SOUTHERN HEALTH
VA
01
—
267258
MAMSI/ALLIANCE
VA
01
—
333848
ANTHEM
VA
01
—
42728
VETRI
VA
Enumeration date
12/17/2005
Last updated
09/29/2012
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