Provider Demographics
NPI:1437155413
Name:WISNER, STEVEN P (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:P
Last Name:WISNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-738-2200
Mailing Address - Fax:360-752-5679
Practice Address - Street 1:4545 CORDATA PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7123
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5679
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019200208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0229988OtherL&I AND CRIME VICTIMS
WA10804OtherREGENCE
WA1437155413Medicaid
WA1904408Medicaid
WA4587498OtherAETNA
WAG 13776Medicare UPIN
WA1437155413Medicaid