Provider Demographics
NPI:1285653188
Name:WALL, DONNA W (CRNA)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:W
Last Name:WALL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18240 PAGES END
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-8001
Mailing Address - Country:US
Mailing Address - Phone:704-892-4061
Mailing Address - Fax:704-892-4295
Practice Address - Street 1:920 CHURCH ST N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2927
Practice Address - Country:US
Practice Address - Phone:704-783-4235
Practice Address - Fax:704-783-2527
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC076344367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8050871Medicaid
NCR41806Medicare UPIN
NC8050871Medicaid