Healthcare Provider Details

I. General information

NPI: 1275991549
Provider Name (Legal Business Name): EMILY LANDIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER DR
SPRINGFIELD OH
45504-2687
US

IV. Provider business mailing address

100 MEDICAL CENTER DR
SPRINGFIELD OH
45504-2687
US

V. Phone/Fax

Practice location:
  • Phone: 937-523-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004563RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: