Provider Demographics
NPI:1285871764
Name:WOLF, EMILY (CST)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:7324 SOUTHWEST FWY STE 1550
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-2053
Mailing Address - Country:US
Mailing Address - Phone:713-779-9800
Mailing Address - Fax:
Practice Address - Street 1:1604 VISA DR STE 1
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2195
Practice Address - Country:US
Practice Address - Phone:309-846-4716
Practice Address - Fax:309-454-1107
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
IL170750363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist