Healthcare Provider Details

I. General information

NPI: 1598977209
Provider Name (Legal Business Name): JASON DANIEL WISTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NORTHEAST MOTHER JOSEPH PLACE
VANCOUVER WA
98664
US

IV. Provider business mailing address

4405 MCCALLISTER PLACE
WASHOUGAL WA
98671
US

V. Phone/Fax

Practice location:
  • Phone: 360-256-2000
  • Fax:
Mailing address:
  • Phone: 909-838-7452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number390200000X
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD60299588
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD157697
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: