Provider Demographics
NPI:1528175841
Name:WISNER, GARY ROYCE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROYCE
Last Name:WISNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:621 S HAM LN STE A
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3533
Mailing Address - Country:US
Mailing Address - Phone:209-368-7777
Mailing Address - Fax:209-368-7778
Practice Address - Street 1:621 S HAM LN STE A
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3533
Practice Address - Country:US
Practice Address - Phone:209-368-7777
Practice Address - Fax:209-368-7778
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2008-05-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA41236207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A412361Medicare PIN
CAF09983Medicare UPIN