Provider Demographics
NPI:1477281863
Name:WISSICK, IAN LEWIS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:LEWIS
Last Name:WISSICK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:LE ROY
Mailing Address - State:NY
Mailing Address - Zip Code:14482-1381
Mailing Address - Country:US
Mailing Address - Phone:585-347-0202
Mailing Address - Fax:
Practice Address - Street 1:3 WEST AVE
Practice Address - Street 2:
Practice Address - City:LE ROY
Practice Address - State:NY
Practice Address - Zip Code:14482-1381
Practice Address - Country:US
Practice Address - Phone:585-768-4550
Practice Address - Fax:585-768-2335
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049084225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist