Provider Demographics
NPI:1043329949
Name:WISNER, JOHN HENRY JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:HENRY
Last Name:WISNER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6522 HEDGE LANE TER
Mailing Address - Street 2:#201
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66226-4872
Mailing Address - Country:US
Mailing Address - Phone:913-972-5730
Mailing Address - Fax:
Practice Address - Street 1:6522 HEDGE LANE TER
Practice Address - Street 2:#201
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66226-4872
Practice Address - Country:US
Practice Address - Phone:913-972-5730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-173972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205162605Medicaid
KS100372770AMedicaid
MO27574013OtherBCBS KANSAS CITY
KS100372770AMedicaid
H26542Medicare UPIN
061A687AMedicare ID - Type Unspecified