Provider Demographics
NPI:1508849340
Name:WISSNER, ERIK (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIK
Middle Name:
Last Name:WISSNER
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 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-304-8431
Mailing Address - Fax:
Practice Address - Street 1:3901 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4988
Practice Address - Country:US
Practice Address - Phone:425-339-5411
Practice Address - Fax:425-339-5448
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138888207RC0000X
WAMD61480639207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ853938Medicaid
AZ853938Medicaid
I03461Medicare UPIN