Provider Demographics
NPI:1932205549
Name:WISTORT, PETER M (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:WISTORT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 W GREENWAY RD STE 107
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-3886
Mailing Address - Country:US
Mailing Address - Phone:602-866-9285
Mailing Address - Fax:602-866-0426
Practice Address - Street 1:3434 W GREENWAY RD STE 107
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-3884
Practice Address - Country:US
Practice Address - Phone:602-866-9285
Practice Address - Fax:602-866-0426
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4940111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ119469Medicare PIN