Provider Demographics
NPI:1043435928
Name:WALL, MEREDITH (PA-C)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7 CAMPUS DRIVE
Mailing Address - Street 2:INTERMED ONSITE AT LLBEAN
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032
Mailing Address - Country:US
Mailing Address - Phone:207-552-7453
Mailing Address - Fax:207-552-7129
Practice Address - Street 1:7 CAMPUS DRIVE
Practice Address - Street 2:INTERMED ONSITE AT LLBEAN
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032
Practice Address - Country:US
Practice Address - Phone:207-552-7453
Practice Address - Fax:207-552-7129
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2309363A00000X
MEPA1521363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant