Healthcare Provider Details

I. General information

NPI: 1417595794
Provider Name (Legal Business Name): EMILY BO LAFOUNTAINE WADDELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY LAFOUNTAINE

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 JEFFERSON AVE
REDWOOD CITY CA
94063-1804
US

IV. Provider business mailing address

2829 UNIVERSITY AVE SE STE 730
MINNEAPOLIS MN
55414-3279
US

V. Phone/Fax

Practice location:
  • Phone: 650-381-0616
  • Fax:
Mailing address:
  • Phone: 612-439-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13612
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68432
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: