Provider Demographics
NPI:1013692771
Name:WISONT, GREGORY (RDN)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:WISONT
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:
Other - Last Name:WIBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16910 NE 131ST PL
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-2189
Mailing Address - Country:US
Mailing Address - Phone:360-969-3698
Mailing Address - Fax:206-292-2163
Practice Address - Street 1:12901 20TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATAC
Practice Address - State:WA
Practice Address - Zip Code:98168-5159
Practice Address - Country:US
Practice Address - Phone:206-720-3987
Practice Address - Fax:206-292-2163
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60974846133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60974846OtherCD