Basic Information
| Provider Information | |||||||||
| NPI: | 1063674190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISNIEWSKI | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923730221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803353 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE STE 308 | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803353 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 20A9062 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | OS 12023 | FL | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | CA209062 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
No ID Information.