Provider Demographics
NPI:1033673587
Name:WALLY, MUSTAPHA (RRT)
Entity Type:Individual
Prefix:
First Name:MUSTAPHA
Middle Name:
Last Name:WALLY
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6775 GOLDEN GATE DR APT 152
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-4369
Mailing Address - Country:US
Mailing Address - Phone:925-487-5539
Mailing Address - Fax:
Practice Address - Street 1:6775 GOLDEN GATE DR APT 152
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-4369
Practice Address - Country:US
Practice Address - Phone:925-487-5539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA272802278C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278C0205XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedCritical Care