MEDICARE: EYE & LASER PHYSICIANS OF WALLA WALLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	MD00034061	WA

General Provider Information

NPI Number	:	1255379798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE & LASER PHYSICIANS OF WALLA WALLA

Provider Business Mailing Address
First Line	:	299 W TIETAN
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-3131
Country	:	US
Telephone Number	:	509-525-2100
Fax Number	:	509-525-0313

Provider Business Practice Location Address
First Line	:	299 W TIETAN ST
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-4363
Country	:	US
Telephone Number	:	509-525-2100
Fax Number	:	509-522-0313

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	LINDA ANNE GUNSHEFSKI
Credential	:	MD
Telephone Number	:	509-525-2100

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	03/15/2016

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