Healthcare Provider Details

I. General information

NPI: 1417061821
Provider Name (Legal Business Name): ANGELINA KELLY VISCARDI WALLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11960 LIONESS WAY STE 260
PARKER CO
80134
US

IV. Provider business mailing address

8101 E LOWRY BLVD STE 230
DENVER CO
80230-7195
US

V. Phone/Fax

Practice location:
  • Phone: 303-344-9090
  • Fax: 720-895-1121
Mailing address:
  • Phone: 303-344-9090
  • Fax: 303-344-1922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2178
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2178
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: