Basic Information
| Provider Information | |||||||||
| NPI: | 1114193976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEICK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | RPAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 HICKSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117143471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165766106 | ||||||||
| FaxNumber: | 5165765801 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 1ST ST | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166638312 | ||||||||
| FaxNumber: | 5166632184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2008 | ||||||||
| LastUpdateDate: | 02/04/2013 | ||||||||
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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 | 363A00000X | 008816 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.