Provider Demographics
NPI:1396000576
Name:WITEK, MIECZYSLAW (MSN,CRNP)
Entity Type:Individual
Prefix:MR
First Name:MIECZYSLAW
Middle Name:
Last Name:WITEK
Suffix:
Gender:M
Credentials:MSN,CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 E PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-1220
Mailing Address - Country:US
Mailing Address - Phone:856-858-1647
Mailing Address - Fax:
Practice Address - Street 1:21 E PALMER AVE
Practice Address - Street 2:
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08108-1220
Practice Address - Country:US
Practice Address - Phone:856-858-1647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP006127B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily