Provider Demographics
NPI:1710032594
Name:WISNIEWSKI, JAENA (MD)
Entity Type:Individual
Prefix:
First Name:JAENA
Middle Name:
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 HAZELWOOD ST STE 310
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1244
Mailing Address - Country:US
Mailing Address - Phone:651-264-1500
Mailing Address - Fax:
Practice Address - Street 1:2945 HAZELWOOD ST STE 310
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1244
Practice Address - Country:US
Practice Address - Phone:651-264-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68895-20207ZP0102X
MN52638207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN220001399Medicare PIN
MN220001523Medicare PIN