Provider Demographics
NPI:1720226863
Name:WIST, ELIZABETH (PA)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:WIST
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 GARDEN ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-4299
Mailing Address - Country:US
Mailing Address - Phone:516-383-5155
Mailing Address - Fax:
Practice Address - Street 1:177 FORT WASHINGTON AVENUE
Practice Address - Street 2:MHB 7GN-435
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-2633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-28
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant