Basic Information
| Provider Information | |||||||||
| NPI: | 1326597071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIERMAN | ||||||||
| FirstName: | ELISSA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANAK | ||||||||
| OtherFirstName: | ELISSA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2087 ROUTE 9 STE 9 | ||||||||
| Address2: | |||||||||
| City: | SEAVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082301148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094865150 | ||||||||
| FaxNumber: | 6094866798 | ||||||||
| Practice Location | |||||||||
| Address1: | 2087 ROUTE 9 | ||||||||
| Address2: | UNIT 9 | ||||||||
| City: | OCEAN VIEW | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094865150 | ||||||||
| FaxNumber: | 6094866798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2016 | ||||||||
| LastUpdateDate: | 06/29/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 25MP00409700 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.