Provider Demographics
NPI:1235157488
Name:WALL, SHELLYANN (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELLYANN
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:90 SOUTHSIDE AVE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-4160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 NORTHPORT AVE
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6009
Practice Address - Country:US
Practice Address - Phone:207-338-2500
Practice Address - Fax:207-505-4590
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-01-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC103723363A00000X
MEPA2003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1235157488Medicaid
NC1235157488Medicaid
NC2757810BMedicare PIN