Provider Demographics
NPI:1245773084
Name:WALLS, THOMAS E
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:WALLS
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 1:3075 N WINDSONG DR STE A
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1208
Mailing Address - Country:US
Mailing Address - Phone:928-350-8780
Mailing Address - Fax:888-674-1228
Practice Address - Street 1:3075 N WINDSONG DR STE A
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314
Practice Address - Country:US
Practice Address - Phone:928-350-8780
Practice Address - Fax:888-674-1228
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN192472363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily