Provider Demographics
NPI:1619640125
Name:WALLE, VARVARA
Entity Type:Individual
Prefix:
First Name:VARVARA
Middle Name:
Last Name:WALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15042 REYNOSA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MURIETA
Mailing Address - State:CA
Mailing Address - Zip Code:95683-9143
Mailing Address - Country:US
Mailing Address - Phone:415-596-0991
Mailing Address - Fax:
Practice Address - Street 1:2300 I ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20052-0011
Practice Address - Country:US
Practice Address - Phone:202-994-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant