Provider Demographics
NPI:1659339356
Name:WISBECK, WILLIAM M (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:M
Last Name:WISBECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 13TH STREET, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201
Mailing Address - Country:US
Mailing Address - Phone:425-297-5597
Mailing Address - Fax:425-297-5598
Practice Address - Street 1:1717 13TH ST
Practice Address - Street 2:STE 200
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1621
Practice Address - Country:US
Practice Address - Phone:425-297-5590
Practice Address - Fax:425-297-5595
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
WAMD000254502085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8308744Medicaid
WA8308744Medicaid
WA001248803Medicare PIN