Healthcare Provider Details

I. General information

NPI: 1639297674
Provider Name (Legal Business Name): JASON PATRICK WISSINGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 N RESERVE ST STE Q
MISSOULA MT
59808-1390
US

IV. Provider business mailing address

PO BOX 12
LIBERTY LAKE WA
99019-0012
US

V. Phone/Fax

Practice location:
  • Phone: 406-327-1850
  • Fax: 406-327-1875
Mailing address:
  • Phone: 866-747-2455
  • Fax: 406-329-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number173T2
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMED-PHYS-LIC-128574
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: