Provider Demographics
NPI:1801887500
Name:KISNER, WENDELL H (MD)
Entity type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:H
Last Name:KISNER
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 1:16025 HIGHLAND BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-5630
Mailing Address - Country:US
Mailing Address - Phone:225-892-5602
Mailing Address - Fax:225-765-4288
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-4454
Practice Address - Fax:225-765-4288
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.010138208200000X
LA0101382086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1150436Medicaid
LAB64894Medicare UPIN
LA1150436Medicaid