Provider Demographics
NPI:1801976923
Name:WALALIYADDA, RANMALI KALYANI (PAC)
Entity type:Individual
Prefix:
First Name:RANMALI
Middle Name:KALYANI
Last Name:WALALIYADDA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
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Mailing Address - Street 1:1448 E CENTER ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4132
Mailing Address - Country:US
Mailing Address - Phone:208-234-1300
Mailing Address - Fax:208-234-1333
Practice Address - Street 1:1448 E CENTER ST
Practice Address - Street 2:SUITE E
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4132
Practice Address - Country:US
Practice Address - Phone:208-234-1300
Practice Address - Fax:208-234-1333
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant