Provider Demographics
NPI:1144829862
Name:WISER, SHAWNA
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:WISER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 41ST AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-5302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 34TH ST N
Practice Address - Street 2:
Practice Address - City:DILWORTH
Practice Address - State:MN
Practice Address - Zip Code:56529-1801
Practice Address - Country:US
Practice Address - Phone:218-233-9833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119408183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist