Basic Information
| Provider Information | |||||||||
| NPI: | 1598823502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISNIEWSKI | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HYGEIA DR | ||||||||
| Address2: | CCHS INC., PHYSICIAN CONTRACTING, SUITE 2502 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026237362 | ||||||||
| FaxNumber: | 3026237374 | ||||||||
| Practice Location | |||||||||
| Address1: | 4735 OGLETOWN STANTON RD | ||||||||
| Address2: | MAP II, SUITES 1201 & 1205 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027331980 | ||||||||
| FaxNumber: | 3027331986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363A00000X | C5-0000561 | DE | X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | C5-0000561 | DE | X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | C5-0000561 | 01 | DE | PROFESSIONAL LICENSE | OTHER |