MEDICARE: MRS. KIMBERLY L WALLER PA-C

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	363AM0700X	Medical Physician Assistant	PA842	NV
2	363A00000X	Physician Assistant	PA01142	OR

Other Identifiers

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

General Provider Information

NPI Number	:	1093782914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY L WALLER PA-C

Provider Business Mailing Address
First Line	:	1701 NW HAWTHORNE AVE
Second Line	:
City	:	GRANTS PASS
State	:	OR
Zip	:	97526-1051
Country	:	US
Telephone Number	:	541-471-3455
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 NW HAWTHORNE AVE
Second Line	:
City	:	GRANTS PASS
State	:	OR
Zip	:	97526-1051
Country	:	US
Telephone Number	:	541-471-3455
Fax Number	:

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

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	10/28/2019

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Directions to “ MRS. KIMBERLY L WALLER PA-C” Practice Location

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