Provider Demographics
NPI:1598858722
Name:RISKO, WANESSA P (MD)
Entity Type:Individual
Prefix:DR
First Name:WANESSA
Middle Name:P
Last Name:RISKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 UNION ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON CENTRE
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2057
Mailing Address - Country:US
Mailing Address - Phone:617-209-3933
Mailing Address - Fax:617-467-5318
Practice Address - Street 1:32 UNION ST
Practice Address - Street 2:
Practice Address - City:NEWTON CENTRE
Practice Address - State:MA
Practice Address - Zip Code:02459-2057
Practice Address - Country:US
Practice Address - Phone:617-564-0123
Practice Address - Fax:617-467-5318
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78884208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3120730Medicaid
MA3120730Medicaid
RI J30309Medicare ID - Type Unspecified