Provider Demographics
NPI:1063526820
Name:WEISS, STANLEY G (PAC)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:G
Last Name:WEISS
Suffix:
Gender:M
Credentials:PAC
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 10863
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28404
Mailing Address - Country:US
Mailing Address - Phone:910-686-5433
Mailing Address - Fax:910-686-6737
Practice Address - Street 1:7491 MARKET STREET
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411
Practice Address - Country:US
Practice Address - Phone:910-686-5433
Practice Address - Fax:910-686-6737
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101125208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
S67098Medicare UPIN