Individual
ELLIE WIESE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1 CAMPUS RD, STATEN ISLAND, NY 10301-4479
(718) 390-3100
Mailing address
1 CAMPUS RD, STATEN ISLAND, NY 10301-4479
(718) 420-4142
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Enumeration date
04/26/2023
Last updated
04/26/2023
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