Provider Demographics
NPI:1346301249
Name:WISNOSKY, COLLEEN LOUISE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:LOUISE
Last Name:WISNOSKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:COLLEEN
Other - Middle Name:LOUISE
Other - Last Name:VENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28070-0497
Mailing Address - Country:US
Mailing Address - Phone:704-377-4009
Mailing Address - Fax:
Practice Address - Street 1:13808 PROFESSIONAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7948
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01621363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical