MEDICARE: DR. MARY SUSAN EMERSON APRN, PHD

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	363LA2200X	Adult Health Nurse Practitioner	063436	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790784452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY SUSAN EMERSON APRN, PHD

Provider Business Mailing Address
First Line	:	2616 TUMBLE BROOK DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-7869
Country	:	US
Telephone Number	:	918-606-0505
Fax Number	:

Provider Business Practice Location Address
First Line	:	2616 TUMBLE BROOK DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-7869
Country	:	US
Telephone Number	:	918-606-0505
Fax Number	:

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	02/17/2015

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