Provider Demographics
NPI:1770543902
Name:WISNIEWSKI, MATT S (CRNA)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:S
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:INOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74036-0190
Mailing Address - Country:US
Mailing Address - Phone:918-543-1020
Mailing Address - Fax:918-543-2103
Practice Address - Street 1:1101 DECATUR ST
Practice Address - Street 2:FIRELANDS REGIONAL MEDICAL CENTER
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:918-543-1020
Practice Address - Fax:918-543-2103
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHRN178864367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH430070791OtherRAILROAD MEDICARE
OH0679841Medicaid
OH0679841Medicaid