MEDICARE: WAVE MEDICAL AESTHETICS

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	363LA2200X	Adult Health Nurse Practitioner

General Provider Information

NPI Number	:	1598583056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAVE MEDICAL AESTHETICS

Provider Business Mailing Address
First Line	:	941 GREAT PLAIN AVE
Second Line	:
City	:	NEEDHAM
State	:	MA
Zip	:	02492-3031
Country	:	US
Telephone Number	:	339-777-5554
Fax Number	:

Provider Business Practice Location Address
First Line	:	941 GREAT PLAIN AVE
Second Line	:
City	:	NEEDHAM
State	:	MA
Zip	:	02492-3031
Country	:	US
Telephone Number	:	339-777-5554
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEBRA A LITKE
Credential	:	NP
Telephone Number	:	339-777-5554

Provider Enumeration Date	:	10/02/2024
Last Update Date	:	10/09/2024

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