Provider Demographics
NPI:1356401103
Name:WISLER, RAE (MD)
Entity type:Individual
Prefix:
First Name:RAE
Middle Name:
Last Name:WISLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4603 NE ST JOHNS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-2587
Mailing Address - Country:US
Mailing Address - Phone:360-254-1814
Mailing Address - Fax:360-254-1828
Practice Address - Street 1:4603 NE ST JOHNS RD
Practice Address - Street 2:SUITE C
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-2587
Practice Address - Country:US
Practice Address - Phone:360-254-1814
Practice Address - Fax:360-254-1828
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA000319842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1090455Medicaid
WA601-864-528OtherBUSINESS ID NUMBER
91-1895126OtherEIN
WAF90372Medicare UPIN
WA115000263Medicare ID - Type Unspecified