Healthcare Provider Details

I. General information

NPI: 1225726664
Provider Name (Legal Business Name): CASSIE NICOLE WISBANG-VASQUEZ DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 E BASELINE RD STE 103
GILBERT AZ
85234-2427
US

IV. Provider business mailing address

2915 E BASELINE RD STE 103
GILBERT AZ
85234-2427
US

V. Phone/Fax

Practice location:
  • Phone: 480-962-4281
  • Fax:
Mailing address:
  • Phone: 480-962-4281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD-001173
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: