Healthcare Provider Details

I. General information

NPI: 1598970477
Provider Name (Legal Business Name): JASON ROMAN WISNIEWSKI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2007
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N RAINBOW BLVD STE 300-307
LAS VEGAS NV
89107-1082
US

IV. Provider business mailing address

7620 E MCKELLIPS RD STE 4-225
SCOTTSDALE AZ
85257-4600
US

V. Phone/Fax

Practice location:
  • Phone: 888-495-4489
  • Fax: 602-865-8090
Mailing address:
  • Phone: 480-687-4164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2016
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: