Provider Demographics
NPI:1104804087
Name:WALLIN, AMY L (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:WALLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1271 8TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-2650
Mailing Address - Country:US
Mailing Address - Phone:515-224-4993
Mailing Address - Fax:515-224-1505
Practice Address - Street 1:1271 8TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-2650
Practice Address - Country:US
Practice Address - Phone:515-224-4993
Practice Address - Fax:515-224-1505
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2015-02-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IAMD-32980208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0186809Medicaid
IA370013781OtherRR MEDICARE
IA1104804087Medicaid
IA1104804087Medicaid
IA719260097Medicare PIN
IA49500Medicare PIN