Healthcare Provider Details

I. General information

NPI: 1356992341
Provider Name (Legal Business Name): EMILY MARIE FUKUDA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2019
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE ML 1013
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.007835
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006108RX
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number50.006108RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: