Provider Demographics
NPI:1245206325
Name:WISNESKI, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WISNESKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 FREEPORT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ASPINWALL
Mailing Address - State:PA
Mailing Address - Zip Code:15215-3035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:241 FREEPORT RD
Practice Address - Street 2:SUITE 3
Practice Address - City:ASPINWALL
Practice Address - State:PA
Practice Address - Zip Code:15215-3035
Practice Address - Country:US
Practice Address - Phone:412-781-8566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028087E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB33498Medicare UPIN
PA024334PD9Medicare ID - Type Unspecified