Provider Demographics
NPI:1619693702
Name:WISNIEWSKI, BETHANY DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:DANIELLE
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 OASIS GRAND BLVD APT 2202
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-1607
Mailing Address - Country:US
Mailing Address - Phone:561-779-0610
Mailing Address - Fax:
Practice Address - Street 1:6150 DIAMOND CENTRE CT UNIT 1200
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7135
Practice Address - Country:US
Practice Address - Phone:239-344-9786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9116636363A00000X
FLPA9116636363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant