Provider Demographics
NPI:1003924903
Name:WEISS, LYNNE
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:WEISS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 WEST GILBERT
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:89 FRENCH STREET
Practice Address - Street 2:SUITE 2300
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901
Practice Address - Country:US
Practice Address - Phone:732-235-6230
Practice Address - Fax:732-235-6620
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0363932080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2306701Medicaid
NJ400054C59Medicare PIN
NJE13269Medicare UPIN