Provider Demographics
NPI:1639220973
Name:WALLNER, JEAN M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:M
Last Name:WALLNER
Suffix:
Gender:F
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 1:7001 N DALE MABRY HWY STE 10
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-3910
Mailing Address - Country:US
Mailing Address - Phone:813-497-9661
Mailing Address - Fax:813-615-8468
Practice Address - Street 1:7001 N DALE MABRY HWY STE 10
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614
Practice Address - Country:US
Practice Address - Phone:813-497-9661
Practice Address - Fax:813-615-8468
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017063300Medicaid
FLVRY4KOtherBLUE CROSS BLUE SHIELD
FLFD417YMedicare PIN
FLVRY4KOtherBLUE CROSS BLUE SHIELD