Healthcare Provider Details

I. General information

NPI: 1114747680
Provider Name (Legal Business Name): EMMA JO MCCOSH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMMA JO WASKOM PA-C

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2326 18TH ST STE 230
COLUMBUS IN
47201-5359
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-376-9261
  • Fax:
Mailing address:
  • Phone: 812-376-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.010257RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004864A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: