Individual
PHILLIP LEE WISE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
326 N BROAD ST, SELINSGROVE, PA 17870-1512
(570) 374-8136
(570) 374-0462
Mailing address
326 N BROAD ST, SELINSGROVE, PA 17870-1512
(570) 374-8136
(570) 374-0462
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OEG001746
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0012999200001
—
PA
01
—
02549200
CAPITAL BLUE CROSS
PA
01
—
T28746
HEALTH ASSURANCE
PA
Enumeration date
11/22/2005
Last updated
04/17/2008
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