Provider Demographics
NPI:1104058742
Name:WISMANN, NICHOLAS GUY (LAC, LMP)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GUY
Last Name:WISMANN
Suffix:
Gender:M
Credentials:LAC, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3714 BUCKNELL DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-4397
Mailing Address - Country:US
Mailing Address - Phone:303-301-4185
Mailing Address - Fax:
Practice Address - Street 1:6881 S HOLLY CIR
Practice Address - Street 2:207
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-1145
Practice Address - Country:US
Practice Address - Phone:303-301-4185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-16
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60099399171100000X
WAMA00023357225700000X
COACU 1492171100000X
COMT-4817225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist