Provider Demographics
NPI:1215043880
Name:WALLA, MEGAN D
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:D
Last Name:WALLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:D
Other - Last Name:SAMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:226 EL ORIENTE
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3140
Mailing Address - Country:US
Mailing Address - Phone:714-425-2287
Mailing Address - Fax:
Practice Address - Street 1:226 EL ORIENTE
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3140
Practice Address - Country:US
Practice Address - Phone:714-425-2287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16731363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABK572ZMedicare PIN