Provider Demographics
NPI:1184488967
Name:SO, EMILY JANE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:JANE
Last Name:SO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 THOMAS JOHNSON DR STE B
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4396
Mailing Address - Country:US
Mailing Address - Phone:301-698-2424
Mailing Address - Fax:
Practice Address - Street 1:63 THOMAS JOHNSON DR STE B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4396
Practice Address - Country:US
Practice Address - Phone:301-698-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant