Provider Demographics
NPI:1275919581
Name:WALLS, CARRIE P (PA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:P
Last Name:WALLS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 JEFFERSON AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-545-7302
Mailing Address - Fax:
Practice Address - Street 1:877 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2807
Practice Address - Country:US
Practice Address - Phone:901-545-8090
Practice Address - Fax:901-545-9529
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TN2833363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant