Individual
DR. MARK EDWIN WISNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PH.D., PA-C
Contact information
Practice address
4101 S 4TH ST, VAMC RM. A541, LEAVENWORTH, KS 66048-5014
(913) 758-5416
(913) 758-4219
Mailing address
4101 S 4TH ST, VAMC RM. A541, LEAVENWORTH, KS 66048-5014
(913) 758-5416
(913) 758-4219
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA 15-000385
KS
363AS0400X
Surgical Physician Assistant
PA-15-000385
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100340730A
—
KS
01
—
426715
BLUE CROSS/BLUE SHIELD
KS
Enumeration date
07/31/2006
Last updated
09/23/2010
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