Provider Demographics
NPI:1992990238
Name:VAUGHN, WALLISA TEJARNETTE (MD)
Entity type:Individual
Prefix:
First Name:WALLISA
Middle Name:TEJARNETTE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 VALLEY VIEW BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-2038
Mailing Address - Country:US
Mailing Address - Phone:540-278-1051
Mailing Address - Fax:
Practice Address - Street 1:850 KEMPSVILLE RD STE 200A
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3920
Practice Address - Country:US
Practice Address - Phone:757-261-5910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101255299207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6341Medicare PIN
SCAA39614784Medicare PIN
SC7153Medicare PIN
SCAA39616341Medicare PIN
SCGP4306OtherMEDICAID GROUP
SCGP4840OtherMEDICAID GROUP
SCGP2626OtherMEDICAID GROUP
SCAA39617153Medicare PIN
SC291990Medicaid