Healthcare Provider Details

I. General information

NPI: 1053894717
Provider Name (Legal Business Name): ELIZABETH WEISSBART WASIK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 GOLDEN CENTER DR STE B
PLACERVILLE CA
95667-6280
US

IV. Provider business mailing address

4212 MISSOURI FLAT RD
PLACERVILLE CA
95667-6269
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-7700
  • Fax:
Mailing address:
  • Phone: 530-621-7700
  • Fax: 518-395-9431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF343571
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95013662
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: