Healthcare Provider Details

I. General information

NPI: 1780212779
Provider Name (Legal Business Name): EMMA LOUISE MESSERICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 FAIRVIEW BLVD
WYOMING MN
55092-8013
US

IV. Provider business mailing address

5200 FAIRVIEW BLVD
WYOMING MN
55092-8013
US

V. Phone/Fax

Practice location:
  • Phone: 651-982-7650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: