1356471692 NPI number — MR. FRANCIS MARION WISHAM PHYSICIAN ASSISTANT

Table of content: MR. FRANCIS MARION WISHAM PHYSICIAN ASSISTANT (NPI 1356471692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356471692 NPI number — MR. FRANCIS MARION WISHAM PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISHAM
Provider First Name:
FRANCIS
Provider Middle Name:
MARION
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356471692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 18TH ST E
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794-3643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-353-3450
Provider Business Mailing Address Fax Number:
229-353-6060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2227 US HWY 41N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-386-5222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  001417 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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