Basic Information
| Provider Information | |||||||||
| NPI: | 1922495001 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WISLER | ||||||||
| FirstName: | RYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702497751 | ||||||||
| FaxNumber: | 9702495029 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702497751 | ||||||||
| FaxNumber: | 9702495029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2015 | ||||||||
| LastUpdateDate: | 05/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 0061512 | CO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 304642 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0061512 | 01 | CO | STATE LICENSE | OTHER |