Provider Demographics
NPI:1790740637
Name:WISNOSKI, JENNIFER ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:WISNOSKI
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 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:295 ESSJAY RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8216
Practice Address - Country:US
Practice Address - Phone:716-565-1234
Practice Address - Fax:716-556-1246
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I45174Medicare UPIN
NYRA8492Medicare ID - Type Unspecified
NY000528315001OtherBLUE CROSS/BLUE SHIELD
NY00027329301OtherUNIVERA
NYRA8492Medicare ID - Type Unspecified