Provider Demographics
NPI:1427061183
Name:WALIN, SUSAN LYN (PA C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYN
Last Name:WALIN
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S WELLS RD
Mailing Address - Street 2:STE 200
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1377
Mailing Address - Country:US
Mailing Address - Phone:805-647-6322
Mailing Address - Fax:805-647-7164
Practice Address - Street 1:200 S WELLS RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004
Practice Address - Country:US
Practice Address - Phone:805-647-6322
Practice Address - Fax:805-647-7164
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R95137Medicare UPIN