Basic Information
| Provider Information | |||||||||
| NPI: | 1740605229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLMAN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6350 CENTER DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579055558 | ||||||||
| FaxNumber: | 7572135762 | ||||||||
| Practice Location | |||||||||
| Address1: | 1503B N ROAD ST | ||||||||
| Address2: | |||||||||
| City: | ELIZABETH CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 279093243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523312044 | ||||||||
| FaxNumber: | 2523311909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2014 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-04837 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 277907 | 01 | NC | MEDCOST | OTHER | 185TX | 01 | NC | BCBS | OTHER | 4159256 | 01 | NC | UNITED HEALTHCARE | OTHER | 1740605229 | 01 | NC | TRICARE | OTHER | 1839PA | 01 | SC | SC MEDICAID | OTHER | P01321199 | 01 | NC | RAILROAD MEDICARE | OTHER | 5650975 | 01 | NC | AETNA | OTHER | 1740605229 | 05 | NC | MEDICAID |