Basic Information
| Provider Information | |||||||||
| NPI: | 1417291923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISSER | ||||||||
| FirstName: | MEREDITH | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GEORGE | ||||||||
| OtherFirstName: | MEREDITH | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7000 STONEWOOD DR | ||||||||
| Address2: | SUITE 151 | ||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150908631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 7000 STONEWOOD DR STE 151 | ||||||||
| Address2: | |||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150907376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249330300 | ||||||||
| FaxNumber: | 7249330456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2012 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA054962 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1033676100001 | 05 | PA | MEDICAID |