Provider Demographics
NPI:1538646542
Name:WISNIEWSKI, JESSICA ROSE (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1555 LONG POND ROAD
Mailing Address - Street 2:DEPT OF SURGERY
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4122
Mailing Address - Country:US
Mailing Address - Phone:585-723-7281
Mailing Address - Fax:585-723-8660
Practice Address - Street 1:1555 LONG POND ROAD
Practice Address - Street 2:DEPT OF SURGERY
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-723-7281
Practice Address - Fax:585-723-8660
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2019-08-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY022240363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05629025Medicaid