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NPI Code Detail

MEDICARE: KELSI V WALLA PA

MEDICARE: KELSI V WALLA PA
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
1363A00000XPhysician AssistantPA2018-0032NM

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1063904464
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELSI V WALLA PA
Provider Business Mailing Address
First Line : 2211 LOMAS BLVD NE
Second Line :
City : ALBUQUERQUE
State : NM
Zip : 87106-2719
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2211 LOMAS BLVD NE
Second Line :
City : ALBUQUERQUE
State : NM
Zip : 87106-2719
Country : US
Telephone Number : 480-751-9804
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/31/2018
Last Update Date : 07/05/2023

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Directions to “ KELSI V WALLA PA” Practice Location

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