Provider Demographics
NPI:1548248008
Name:WALLMAN, CAROL M
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:WALLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 MAXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3972
Mailing Address - Country:US
Mailing Address - Phone:303-544-5777
Mailing Address - Fax:303-544-5775
Practice Address - Street 1:4747 ARAPAHOE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1133
Practice Address - Country:US
Practice Address - Phone:720-854-7152
Practice Address - Fax:720-854-7114
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0637363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94271542Medicaid
COC537388Medicare PIN
COQ20435Medicare UPIN
CO537388Medicare ID - Type Unspecified