Healthcare Provider Details

I. General information

NPI: 1720480304
Provider Name (Legal Business Name): JACQUELINE WALLENBORN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 THOMPSON ST
HENDERSONVILLE NC
28792-2806
US

IV. Provider business mailing address

628 NEW HAW CREEK RD
ASHEVILLE NC
28805-1935
US

V. Phone/Fax

Practice location:
  • Phone: 828-697-3232
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: