Provider Demographics
NPI:1982231205
Name:REGODON WALLIN, AMANDA MATILDA (MD, MPH)
Entity Type:Individual
Prefix:
First Name:AMANDA MATILDA
Middle Name:
Last Name:REGODON WALLIN
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 PARNASSUS AVENUE, BOX-0984
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0984
Mailing Address - Country:US
Mailing Address - Phone:415-476-7527
Mailing Address - Fax:
Practice Address - Street 1:401 PARNASSUS AVENUE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-0984
Practice Address - Country:US
Practice Address - Phone:415-476-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPTL40102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program