Individual
DR. JASON DANIEL WISTER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
400 NORTHEAST MOTHER JOSEPH PLACE, VANCOUVER, WA 98664
(360) 256-2000
Mailing address
4405 MCCALLISTER PLACE, WASHOUGAL, WA 98671
(909) 838-7452
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
390200000X
CA
2080N0001X
Neonatal-Perinatal Medicine Physician
MD157697
OR
2080N0001X
Neonatal-Perinatal Medicine Physician
MD60299588
WA
Other
Enumeration date
05/04/2007
Last updated
09/06/2012
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