MEDICARE: EMILY RENEE TODD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1447813837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY RENEE TODD PA

Provider Business Mailing Address
First Line	:	8 N JEFFERSON ST APT 506
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24016-1935
Country	:	US
Telephone Number	:	336-972-4743
Fax Number	:

Provider Business Practice Location Address
First Line	:	2020 N PEACE HAVEN RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-4851
Country	:	US
Telephone Number	:	336-768-1280
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2019
Last Update Date	:	01/16/2020

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