Provider Demographics
NPI:1609822543
Name:WALLNER, DANIEL A (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:WALLNER
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 1:752 N HIGH POINT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2236
Mailing Address - Country:US
Mailing Address - Phone:608-824-4000
Mailing Address - Fax:608-824-4919
Practice Address - Street 1:752 N HIGH POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2236
Practice Address - Country:US
Practice Address - Phone:608-824-4000
Practice Address - Fax:608-824-4919
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI275-023363AM0700X
WI275-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1609822543Medicaid
WI42962300Medicaid
WI046274150Medicare PIN
WI970010929Medicare PIN
R02465Medicare UPIN
WI5399OtherDEAN HEALTH INSURANCE