MEDICARE: EMILIE WASSERMAN

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	207Q00000X	Family Medicine Physician	285977	NY
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207Q00000X	Family Medicine Physician	64750	AZ

General Provider Information

NPI Number	:	1649512526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILIE WASSERMAN

Provider Business Mailing Address
First Line	:	4751 N 15TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-3707
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4751 N 15TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-3707
Country	:	US
Telephone Number	:	602-277-7526
Fax Number	:

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

Provider Enumeration Date	:	03/19/2013
Last Update Date	:	10/14/2021

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Directions to “ EMILIE WASSERMAN ” Practice Location

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