MEDICARE: EMILY SELEST WALCZAK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0110011290	VA

General Provider Information

NPI Number	:	1316827926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY SELEST WALCZAK PA-C

Provider Business Mailing Address
First Line	:	3071 TURTLE COVE CT
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33903-6920
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3071 TURTLE COVE CT
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33903-6920
Country	:	US
Telephone Number	:	540-241-3107
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2025
Last Update Date	:	09/04/2025

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