Provider Demographics
NPI:1598771586
Name:WISNER, MARK EDWIN (PHD, PA-C)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWIN
Last Name:WISNER
Suffix:
Gender:M
Credentials:PHD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 S 4TH ST
Mailing Address - Street 2:VAMC RM. A541
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5014
Mailing Address - Country:US
Mailing Address - Phone:913-758-5416
Mailing Address - Fax:913-758-4219
Practice Address - Street 1:4101 S 4TH ST
Practice Address - Street 2:VAMC RM. A541
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5014
Practice Address - Country:US
Practice Address - Phone:913-758-5416
Practice Address - Fax:913-758-4219
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSPA 15-000385363AM0700X
KSPA-15-000385363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100340730AMedicaid
KS426715OtherBLUE CROSS/BLUE SHIELD
KS100340730AMedicaid
KSS55198Medicare UPIN