MEDICARE: LIBBI WISSEKERKE 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	PA8171	MA
2	363A00000X	Physician Assistant	PA01129	RI

General Provider Information

NPI Number	:	1497217400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIBBI WISSEKERKE PA-C

Provider Business Mailing Address
First Line	:	593 EDDY ST
Second Line	:
City	:	PROVIDENCE
State	:	RI
Zip	:	02903-4923
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	593 EDDY ST
Second Line	:
City	:	PROVIDENCE
State	:	RI
Zip	:	02903-4923
Country	:	US
Telephone Number	:	401-444-4000
Fax Number	:

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

Provider Enumeration Date	:	04/01/2019
Last Update Date	:	12/15/2025

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Directions to “ LIBBI WISSEKERKE PA-C” Practice Location

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