Provider Demographics
NPI:1083300123
Name:WALL, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LLOYD LN
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2208
Mailing Address - Country:US
Mailing Address - Phone:917-359-1933
Mailing Address - Fax:
Practice Address - Street 1:LINDENHURST MIDDLE SCHOOL
Practice Address - Street 2:350 SOUTH WELLWOOD AVE
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757
Practice Address - Country:US
Practice Address - Phone:631-867-3510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY447785364SS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SS0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistSchoolGroup - Single Specialty