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Individual
LUCY-BERTHA WALLANG
Active
Individual
LUCY-BERTHA WALLANG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
004665
GA
363AM0700X
Medical Physician Assistant
004665
GA
363AM0700X
Medical Physician Assistant
026102-01
NY
363AM0700X
Medical Physician Assistant
1131-23
WI
363AM0700X
Medical Physician Assistant
124154
IA
363AM0700X
Medical Physician Assistant
200001685
DC
363AM0700X
Medical Physician Assistant
58593
CA
363AM0700X
Medical Physician Assistant
9117305
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01076922
AMERIGROUP
GA
01
—
11143
BLUE CROSS BLUE SHIELD
GA
01
—
333656
WELLCARE
GA
05
—
723874491
—
GA
05
—
723874491A
—
GA
05
—
723874491B
—
GA
Enumeration date
05/17/2006
Last updated
06/06/2024
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