Provider Demographics
NPI:1073550141
Name:WISMAN, JOHN A (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:WISMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 116TH AVE NE STE 101
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3043
Mailing Address - Country:US
Mailing Address - Phone:425-637-0094
Mailing Address - Fax:425-453-8298
Practice Address - Street 1:1800 116TH AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3043
Practice Address - Country:US
Practice Address - Phone:425-637-0094
Practice Address - Fax:425-453-8298
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601 847 969111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB34532OtherPIN NUMBER
WAAB34532OtherPIN NUMBER
WAT91048Medicare UPIN