Provider Demographics
NPI:1114963022
Name:WALL, DEANNA M (PA)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:M
Last Name:WALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:DEANNA
Other - Middle Name:M
Other - Last Name:OSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:75 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-5500
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00511363A00000X, 363AM0700X
MAPA7360363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP73424Medicare UPIN
GAP73424Medicare UPIN