Provider Demographics
NPI:1720056245
Name:WISNER, DAVID E (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:E
Last Name:WISNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BIRCHWOOD AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1704
Mailing Address - Country:US
Mailing Address - Phone:360-676-1610
Mailing Address - Fax:360-676-2459
Practice Address - Street 1:470 BIRCHWOOD AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1781
Practice Address - Country:US
Practice Address - Phone:360-676-1610
Practice Address - Fax:360-676-2459
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016552025209174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1807700Medicaid
WA001400257Medicare ID - Type Unspecified
WA1807700Medicaid