Provider Demographics
NPI:1922495001
Name:WISLER, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WISLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-4273
Mailing Address - Country:US
Mailing Address - Phone:970-249-7751
Mailing Address - Fax:970-249-5029
Practice Address - Street 1:300 S NEVADA AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4273
Practice Address - Country:US
Practice Address - Phone:970-249-7751
Practice Address - Fax:970-249-5029
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CO0061512207R00000X
LA304642207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0061512OtherSTATE LICENSE