Provider Demographics
NPI:1114008372
Name:BLOCK WIENER, TAMAR A (PAC)
Entity type:Individual
Prefix:
First Name:TAMAR
Middle Name:A
Last Name:BLOCK WIENER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TAMAR
Other - Middle Name:A
Other - Last Name:BLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:90 MATAWAN RD STE 302
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-2653
Mailing Address - Country:US
Mailing Address - Phone:732-441-7177
Mailing Address - Fax:732-441-7165
Practice Address - Street 1:807 N HADDON AVE STE 1
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-1749
Practice Address - Country:US
Practice Address - Phone:856-330-6260
Practice Address - Fax:833-606-0166
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052662363A00000X, 363AM0700X, 363AS0400X
NJ25MP00147100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA052662OtherPA LICENSE NUMBER
PA50063512OtherBLUE CROSS/KEYSTONE CENTRAL
PA105894EDCMedicare PIN