Provider Demographics
NPI:1689135790
Name:WISNIEWSKI, JACOB ALFRED (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ALFRED
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-1604
Mailing Address - Country:US
Mailing Address - Phone:252-522-7000
Mailing Address - Fax:
Practice Address - Street 1:100 AIRPORT RD FL 4
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1604
Practice Address - Country:US
Practice Address - Phone:252-522-7197
Practice Address - Fax:252-522-7288
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-02277207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine