Provider Demographics
NPI:1598970477
Name:WISNIEWSKI, JASON ROMAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ROMAN
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:7620 E MCKELLIPS RD STE 4-225
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-4600
Mailing Address - Country:US
Mailing Address - Phone:480-687-4164
Mailing Address - Fax:
Practice Address - Street 1:500 N RAINBOW BLVD STE 300-307
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1082
Practice Address - Country:US
Practice Address - Phone:888-495-4489
Practice Address - Fax:602-865-8090
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2016213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery