Provider Demographics
NPI:1073680690
Name:WEISS, SUSAN E (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:WEISS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-5317
Mailing Address - Country:US
Mailing Address - Phone:718-963-7933
Mailing Address - Fax:212-271-7234
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5317
Practice Address - Country:US
Practice Address - Phone:718-963-7933
Practice Address - Fax:718-630-3110
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01854282Medicaid
NY331951Medicare Oscar/Certification
NY331951Medicare ID - Type Unspecified
NY01854282Medicaid