Provider Demographics
NPI:1801082334
Name:WALTER MISIRLI, JEANINE LYNN (MD)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:LYNN
Last Name:WALTER MISIRLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1001 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5134
Mailing Address - Country:US
Mailing Address - Phone:916-746-6726
Mailing Address - Fax:916-746-4519
Practice Address - Street 1:1001 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-5134
Practice Address - Country:US
Practice Address - Phone:916-746-6726
Practice Address - Fax:916-746-4519
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97864207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine