Provider Demographics
NPI:1740605229
Name:WALLMAN, REBECCA ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:WALLMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 N ROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3473
Mailing Address - Country:US
Mailing Address - Phone:252-384-2518
Mailing Address - Fax:
Practice Address - Street 1:1144 N ROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3473
Practice Address - Country:US
Practice Address - Phone:252-384-2518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007289363A00000X
NC0010-04837363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1740605229Medicaid
SC1839PAOtherSC MEDICAID
NC277907OtherMEDCOST
NC5650975OtherAETNA
NCP01321199OtherRAILROAD MEDICARE
NC1740605229OtherTRICARE
NC185TXOtherBCBS
NC4159256OtherUNITED HEALTHCARE
NCNCH135AMedicare PIN