Provider Demographics
NPI:1508420514
Name:ANNIS, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:ANNIS
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 1:830 MADISON ST
Mailing Address - Street 2:APT 530
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-6857
Mailing Address - Country:US
Mailing Address - Phone:908-247-3622
Mailing Address - Fax:
Practice Address - Street 1:1365 MOHAWK DR
Practice Address - Street 2:
Practice Address - City:MOUNTAINSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07092-1820
Practice Address - Country:US
Practice Address - Phone:908-247-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027497363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant