# LUCY-BERTHA WALLANG

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1538111539
- **Gender:** F
- **Credential:** PA-C

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363A00000X | Physician Assistant | 004665 | GA | Yes |
| 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

- **Enumeration date:** 05/17/2006
- **Last updated:** 06/06/2024

## 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 |