Provider Demographics
NPI:1255065694
Name:WISNEWSKI, KATHRYN ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:WISNEWSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ELIZABETH
Other - Last Name:QUEENAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:333 SCHOOL ST STE 112A
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 SCHOOL ST STE 112A
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5336
Practice Address - Country:US
Practice Address - Phone:401-728-6990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant