Provider Demographics
NPI:1558099507
Name:WISNIEWSKI-TOP, CONNOR (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:WISNIEWSKI-TOP
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:CONNOR
Other - Middle Name:
Other - Last Name:WISMIEWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:663 JORDAN ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4748
Mailing Address - Country:US
Mailing Address - Phone:318-222-8892
Mailing Address - Fax:318-222-8893
Practice Address - Street 1:663 JORDAN ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4748
Practice Address - Country:US
Practice Address - Phone:318-222-8892
Practice Address - Fax:318-222-8893
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT38752225100000X
LA11682R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist