MEDICARE: DR. JASON OWEN WALLIN DC

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	111N00000X	Chiropractor	3838	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	55F56BL	OTHER	MN	BCBS

General Provider Information

NPI Number	:	1679628309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON OWEN WALLIN DC

Provider Business Mailing Address
First Line	:	4717 HIAWATHA AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-3928
Country	:	US
Telephone Number	:	612-721-2146
Fax Number	:

Provider Business Practice Location Address
First Line	:	4717 HIAWATHA AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-3928
Country	:	US
Telephone Number	:	612-721-2146
Fax Number	:

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

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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