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General NPI Number Information
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NPI Number | 1962439547
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Entity Type | Individual
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Provider Name | KRISTOFER MICHAEL WALLMAN MPAS, PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/27/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | TWIN PORTS VA OUTPATIENT CLINIC 3520 TOWER AVE.
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City | SUPERIOR
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State | WI
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Zip | 54880-5335
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Country | US
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Telephone | 715-398-2931
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Fax | 715-398-2923
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Provider Business Mailing Address
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Address Line | 94105 PAULUS RD
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City | STURGEON LAKE
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State | MN
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Zip | 55783-3812
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Country | US
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Telephone | 218-485-5793
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 9285
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License Number State | MN
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