| NPI | 1679042410 |
|---|---|
| Former Name | THERESA RAE WALLNER |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0005489) |
| Enumeration Date | 2018-11-23 |
| Last Update Date | 2021-07-13 |