Basic Information
| Provider Information | |||||||||
| NPI: | 1720226863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIST | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 941 GARDEN ST APT 3 | ||||||||
| Address2: | |||||||||
| City: | HOBOKEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070304299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163835155 | ||||||||
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| Practice Location | |||||||||
| Address1: | 177 FORT WASHINGTON AVENUE | ||||||||
| Address2: | MHB 7GN-435 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052633 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2009 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 011195 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.