Healthcare Provider Details

I. General information

NPI: 1821393000
Provider Name (Legal Business Name): LYDIA R EMNOTT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 03/07/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2654 S ONEIDA ST STE 102
GREEN BAY WI
54304-5330
US

IV. Provider business mailing address

10001 W INNOVATION DR STE 200
MILWAUKEE WI
53226-4851
US

V. Phone/Fax

Practice location:
  • Phone: 888-938-3838
  • Fax: 888-919-1083
Mailing address:
  • Phone: 888-938-3838
  • Fax: 888-919-1083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number014440
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7148
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: