Provider Demographics
NPI:1750415832
Name:WISNIEWSKI, DEBRA (PA)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:WISNIEWSKI
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:PO BOX 415750
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5750
Mailing Address - Country:US
Mailing Address - Phone:908-851-8602
Mailing Address - Fax:908-686-8758
Practice Address - Street 1:695 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7200
Practice Address - Country:US
Practice Address - Phone:908-851-8602
Practice Address - Fax:908-686-8758
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00051100363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00051100OtherSTATE MEDICAL LICENSE