Basic Information
| Provider Information | |||||||||
| NPI: | 1861689192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAHL | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10115 W FOREST HILL BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334143105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617982425 | ||||||||
| FaxNumber: | 5617986356 | ||||||||
| Practice Location | |||||||||
| Address1: | 10115 W FOREST HILL BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334143105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617982425 | ||||||||
| FaxNumber: | 5617986356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 10/01/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9100955 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA9100955 | 01 | FL | FL STATE LICENSE | OTHER |