Provider Demographics
NPI:1679661854
Name:WALLNER, TIMOTHY A (PA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:WALLNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2709
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33539-2709
Mailing Address - Country:US
Mailing Address - Phone:813-788-1400
Mailing Address - Fax:813-788-7691
Practice Address - Street 1:38035 MEDICAL CENTER AVE
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33540-1384
Practice Address - Country:US
Practice Address - Phone:813-788-1400
Practice Address - Fax:813-788-7691
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003396363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9104784OtherFL LICENSE