Individual
MS. JEAN M. WALLNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.-C
Contact information
Practice address
7001 N DALE MABRY HWY STE 10, TAMPA, FL 33614
(813) 497-9661
(813) 615-8468
Mailing address
7001 N DALE MABRY HWY STE 10, TAMPA, FL 33614-3910
(813) 497-9661
(813) 615-8468
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA9104785
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
017063300
—
FL
01
—
VRY4K
BLUE CROSS BLUE SHIELD
FL
Enumeration date
01/15/2007
Last updated
02/12/2019
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