Provider Demographics
NPI:1912251356
Name:WALLERSTEDT, SUNJIN
Entity type:Individual
Prefix:
First Name:SUNJIN
Middle Name:
Last Name:WALLERSTEDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUNJIN
Other - Middle Name:
Other - Last Name:LYOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1619 POSSUM PATH
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-4766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 CHERRY RIDGE ST STE D400
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230
Practice Address - Country:US
Practice Address - Phone:210-692-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160030989225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant