Provider Demographics
NPI:1811090418
Name:WISNER, EDWIN GEORGE (AT)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:GEORGE
Last Name:WISNER
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 RUSH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311
Mailing Address - Country:US
Mailing Address - Phone:937-592-1625
Mailing Address - Fax:937-592-3489
Practice Address - Street 1:2200 TIMBER TRL
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-9039
Practice Address - Country:US
Practice Address - Phone:937-592-1625
Practice Address - Fax:937-592-3489
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT5772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer