Healthcare Provider Details

I. General information

NPI: 1477444040
Provider Name (Legal Business Name): BRIAN WISMAR
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 CAPITOL WAY S APT 15
OLYMPIA WA
98501-1231
US

IV. Provider business mailing address

915 CAPITOL WAY S APT 15
OLYMPIA WA
98501-1231
US

V. Phone/Fax

Practice location:
  • Phone: 253-254-6336
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: