Provider Demographics
NPI:1508291170
Name:WACKS, EMILY (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WACKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1284 BEACON ST APT 215
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3733
Mailing Address - Country:US
Mailing Address - Phone:414-690-3515
Mailing Address - Fax:
Practice Address - Street 1:185 PILGRIM RD
Practice Address - Street 2:CARDIOLOGY BAKER 4
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:414-690-3515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4811363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant