Provider Demographics
NPI:1235583279
Name:WALL, ALYSSA EILEEN (MD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:EILEEN
Last Name:WALL
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 1:55 N GILBERT ST STE 2101
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4957
Mailing Address - Country:US
Mailing Address - Phone:732-842-6677
Mailing Address - Fax:
Practice Address - Street 1:55 N GILBERT ST STE 2101
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07701-4957
Practice Address - Country:US
Practice Address - Phone:732-842-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282NC2000X
NJ25MA10606100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No282NC2000XHospitalsGeneral Acute Care HospitalChildren