Provider Demographics
NPI:1417419797
Name:WEIST, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WEIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BRANDT-PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:911 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-2250
Mailing Address - Country:US
Mailing Address - Phone:609-387-8787
Mailing Address - Fax:609-386-8640
Practice Address - Street 1:911 SUNSET RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08016-2250
Practice Address - Country:US
Practice Address - Phone:609-387-8787
Practice Address - Fax:609-386-8640
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00513000363A00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant