MEDICARE: ANDREW MICHAEL WALLIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker		CA

General Provider Information

NPI Number	:	1053253997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW MICHAEL WALLIN

Provider Business Mailing Address
First Line	:	12698 ANDRETTI ST
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92553-5203
Country	:	US
Telephone Number	:	951-892-9873
Fax Number	:

Provider Business Practice Location Address
First Line	:	4065 COUNTY CIRCLE DR
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92503-3410
Country	:	US
Telephone Number	:	951-892-9873
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2026
Last Update Date	:	04/08/2026

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