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General NPI Number Information
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NPI Number | 1083829162
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Entity Type | Individual
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Provider Name | MARK ANDREW WISNER D.O.
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Gender | Male
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Dates
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Enumeration Date | 05/11/2007
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Last Update Date | 02/11/2025
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Provider Practice Location Address
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Address Line | 1109 FORD ST
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City | GOLDEN
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State | CO
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Zip | 80401-1176
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Country | US
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Telephone | 303-277-2138
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 399
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City | KREMMLING
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State | CO
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Zip | 80459-0399
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Country | US
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Telephone | 970-887-5800
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | CO 44052
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License Number State | CO
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