Provider Demographics
NPI:1508969551
Name:WALLMAN, RUSTY (PT)
Entity Type:Individual
Prefix:
First Name:RUSTY
Middle Name:
Last Name:WALLMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7872 CENTURY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317
Mailing Address - Country:US
Mailing Address - Phone:952-448-9081
Mailing Address - Fax:952-448-9088
Practice Address - Street 1:7872 CENTURY BOULEVARD
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317
Practice Address - Country:US
Practice Address - Phone:952-448-9081
Practice Address - Fax:952-448-9088
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN69352251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports