Provider Demographics
NPI:1043283872
Name:WALLROFF, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:WALLROFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CHRISTIAN AVE
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:OH
Mailing Address - Zip Code:44425-2008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:313 NORTH STREET
Practice Address - Street 2:
Practice Address - City:WEST MIDDLESEX
Practice Address - State:PA
Practice Address - Zip Code:16159
Practice Address - Country:US
Practice Address - Phone:724-528-2513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001620L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOA000311LOtherOSTEOPATHIC PA
PAMA001620LOtherLICENSE