Healthcare Provider Details

I. General information

NPI: 1548545189
Provider Name (Legal Business Name): EMMANUEL ESIANOR PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 WESTHILL DR STE 200
WAUSAU WI
54401-3771
US

IV. Provider business mailing address

2800 WESTHILL DR STE 200
WAUSAU WI
54401-3771
US

V. Phone/Fax

Practice location:
  • Phone: 715-843-1000
  • Fax: 715-843-1001
Mailing address:
  • Phone: 715-843-1000
  • Fax: 715-843-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3086-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: