Provider Demographics
NPI:1215133509
Name:WEISE, CRAIG ALAN (MS, ANP)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ALAN
Last Name:WEISE
Suffix:
Gender:M
Credentials:MS, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 DRIVING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1059
Mailing Address - Country:US
Mailing Address - Phone:315-395-2213
Mailing Address - Fax:315-359-2139
Practice Address - Street 1:1304 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1059
Practice Address - Country:US
Practice Address - Phone:315-359-2133
Practice Address - Fax:315-359-2139
Is Sole Proprietor?:No
Enumeration Date:2007-06-23
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF-304637363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB6263Medicare PIN