Healthcare Provider Details

I. General information

NPI: 1548355191
Provider Name (Legal Business Name): WALTER MERLE WALLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4526 FEDERAL AVE BLDG 9
EVERETT WA
98203
US

IV. Provider business mailing address

4526 FEDERAL AVE BLDG 9
EVERETT WA
98203
US

V. Phone/Fax

Practice location:
  • Phone: 425-349-6320
  • Fax: 425-349-6325
Mailing address:
  • Phone: 425-349-6320
  • Fax: 425-349-6325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD00014381
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: