Provider Demographics
NPI:1275517856
Name:HOSN, WALLY (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLY
Middle Name:
Last Name:HOSN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1250 PEACH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2837
Mailing Address - Country:US
Mailing Address - Phone:805-541-0330
Mailing Address - Fax:805-541-6809
Practice Address - Street 1:1250 PEACH ST
Practice Address - Street 2:SUITE D
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2837
Practice Address - Country:US
Practice Address - Phone:805-541-0330
Practice Address - Fax:805-541-6809
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA69516208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA69516Medicare PIN
CAH21034Medicare UPIN