Provider Demographics
NPI:1306374210
Name:WISSNER, ROBERT J (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WISSNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 22ND ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6558
Mailing Address - Country:US
Mailing Address - Phone:503-967-6771
Mailing Address - Fax:503-385-8421
Practice Address - Street 1:1100 22ND ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6558
Practice Address - Country:US
Practice Address - Phone:503-967-6771
Practice Address - Fax:503-385-8421
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO214552208100000X, 2081P2900X, 2081P2900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program