MEDICARE: DR. JASON RANDALL WISHIN SR. PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1240476	TX

General Provider Information

NPI Number	:	1184049546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON RANDALL WISHIN SR. PT

Provider Business Mailing Address
First Line	:	1015 N CARROLL AVE
Second Line	:	SUITE 104
City	:	DALLAS
State	:	TX
Zip	:	75204-6613
Country	:	US
Telephone Number	:	214-887-6580
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 N CARROLL AVE
Second Line	:	SUITE 104
City	:	DALLAS
State	:	TX
Zip	:	75204-6613
Country	:	US
Telephone Number	:	214-887-6580
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2014
Last Update Date	:	02/21/2014

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