Provider Demographics
NPI:1962439547
Name:WALLMAN, KRISTOFER MICHAEL (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTOFER
Middle Name:MICHAEL
Last Name:WALLMAN
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94105 PAULUS RD
Mailing Address - Street 2:
Mailing Address - City:STURGEON LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55783-3812
Mailing Address - Country:US
Mailing Address - Phone:218-485-5793
Mailing Address - Fax:
Practice Address - Street 1:TWIN PORTS VA OUTPATIENT CLINIC
Practice Address - Street 2:3520 TOWER AVE.
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5335
Practice Address - Country:US
Practice Address - Phone:715-398-2931
Practice Address - Fax:715-398-2923
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9285363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIVAD000Medicare UPIN