Provider Demographics
NPI:1275709560
Name:WISNIOWIECKI, PAT A (RD,LD)
Entity Type:Individual
Prefix:
First Name:PAT
Middle Name:A
Last Name:WISNIOWIECKI
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2808
Mailing Address - Country:US
Mailing Address - Phone:936-539-7497
Mailing Address - Fax:
Practice Address - Street 1:504 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2808
Practice Address - Country:US
Practice Address - Phone:936-539-7497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT00309133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered