MEDICARE: BETHANY DANIELLE WISNIEWSKI PA-C

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	363A00000X	Physician Assistant	PA9116636	FL
2	363AS0400X	Surgical Physician Assistant	PA9116636	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619693702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHANY DANIELLE WISNIEWSKI PA-C

Provider Business Mailing Address
First Line	:	3040 OASIS GRAND BLVD APT 2202
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33916-1607
Country	:	US
Telephone Number	:	561-779-0610
Fax Number	:

Provider Business Practice Location Address
First Line	:	6150 DIAMOND CENTRE CT UNIT 1200
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-7135
Country	:	US
Telephone Number	:	239-344-9786
Fax Number	:

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

Provider Enumeration Date	:	10/19/2022
Last Update Date	:	02/13/2025

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