Provider Demographics
NPI:1548355191
Name:WALLIS, WALTER MERLE (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:MERLE
Last Name:WALLIS
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Gender:M
Credentials:MD
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Mailing Address - Street 1:4526 FEDERAL AVE
Mailing Address - Street 2:BLDG 9
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203
Mailing Address - Country:US
Mailing Address - Phone:425-349-6320
Mailing Address - Fax:425-349-6325
Practice Address - Street 1:4526 FEDERAL AVE
Practice Address - Street 2:BLDG 9
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203
Practice Address - Country:US
Practice Address - Phone:425-349-6320
Practice Address - Fax:425-349-6325
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
WAMD000143812084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAO5881Medicare UPIN