Healthcare Provider Details

I. General information

NPI: 1912251356
Provider Name (Legal Business Name): SUNJIN WALLERSTEDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUNJIN LYOU

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 CHERRY RIDGE ST STE D400
SAN ANTONIO TX
78230
US

IV. Provider business mailing address

1619 POSSUM PATH
SAN ANTONIO TX
78232-4766
US

V. Phone/Fax

Practice location:
  • Phone: 210-692-0222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP160030989
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: