Provider Demographics
NPI:1427589670
Name:WALLSTROM, DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WALLSTROM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 ALLEN STREET
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-747-3639
Mailing Address - Fax:802-747-6207
Practice Address - Street 1:22 STATION AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2092
Practice Address - Country:US
Practice Address - Phone:207-406-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MEPA2300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical