MEDICARE: LISA WALLIN ANP-C, CWS

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	163WW0000X	Wound Care Registered Nurse	30302641	NY
2	363L00000X	Nurse Practitioner	302641	NY
3	363LA2200X	Adult Health Nurse Practitioner	302641	NY

General Provider Information

NPI Number	:	1114933421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA WALLIN ANP-C, CWS

Provider Business Mailing Address
First Line	:	160 SAWGRASS DR STE 130
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-4655
Country	:	US
Telephone Number	:	585-262-9100
Fax Number	:	585-256-2046

Provider Business Practice Location Address
First Line	:	160 SAWGRASS DR STE 130
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-4655
Country	:	US
Telephone Number	:	585-262-9100
Fax Number	:	585-256-2046

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/05/2023

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