Provider Demographics
NPI:1902876154
Name:WISNER, ROBERT R JR (PA C)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:R
Last Name:WISNER
Suffix:JR
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:419-468-0522
Mailing Address - Fax:
Practice Address - Street 1:269 PORTLAND WAY S
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833-2312
Practice Address - Country:US
Practice Address - Phone:419-462-4560
Practice Address - Fax:419-462-4566
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH375510OtherMEDICARE
OH0083696Medicaid