Individual
MRS. KIMBERLY L WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1701 NW HAWTHORNE AVE, GRANTS PASS, OR 97526-1051
(541) 471-3455
Mailing address
1701 NW HAWTHORNE AVE, GRANTS PASS, OR 97526-1051
(541) 471-3455
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA01142
OR
363AM0700X
Medical Physician Assistant
PA842
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100503226
—
NV
05
—
100503581
—
NV
Enumeration date
03/01/2006
Last updated
10/28/2019
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