Provider Demographics
NPI:1609690890
Name:WISEMAN, GINA (PTA)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4144 WATKINS RD
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-6156
Mailing Address - Country:US
Mailing Address - Phone:330-636-6829
Mailing Address - Fax:
Practice Address - Street 1:122 MEDINA RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-9650
Practice Address - Country:US
Practice Address - Phone:330-239-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA013799225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant