Basic Information
| Provider Information | |||||||||
| NPI: | 1093197923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASTAK | ||||||||
| FirstName: | ALLISON | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C, RN, CCRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SEIPP | ||||||||
| OtherFirstName: | ALLISON | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1910 OUTLET CENTER DR | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930360677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054852400 | ||||||||
| FaxNumber: | 8054853025 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 OUTLET CENTER DR | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930360677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054852400 | ||||||||
| FaxNumber: | 8054853025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2015 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024172720 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1093197923 | 05 | VA | MEDICAID | 1093197923 | 01 | VA | USA MANAGED CARE | OTHER | 1093197923 | 01 | VA | MULTIPLAN | OTHER | -029 | 01 | VA | TRICARE/CHAMPUS | OTHER | 1093197923 | 01 | VA | CORVEL | OTHER | 1093197923 | 01 | VA | VIRGINIA PREMIER HEALTH PLAN | OTHER | 1093197923 | 01 | VA | OPTIMA HEALTH | OTHER | 1093197923 | 05 | NC | MEDICAID |