Provider Demographics
NPI:1922066117
Name:WALLIS, COLLEEN RAE (PAC)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:RAE
Last Name:WALLIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:RAE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:3605 MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2923
Mailing Address - Country:US
Mailing Address - Phone:218-262-3441
Mailing Address - Fax:218-362-6989
Practice Address - Street 1:3605 MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2923
Practice Address - Country:US
Practice Address - Phone:218-262-3441
Practice Address - Fax:218-362-6989
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 1069736363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS48605Medicare UPIN