Provider Demographics
NPI:1376278119
Name:WALLS, MEAGAN (PA)
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:
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 1:6482 82ND PL
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-2341
Mailing Address - Country:US
Mailing Address - Phone:917-561-2538
Mailing Address - Fax:
Practice Address - Street 1:167 E MERRICK RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-5925
Practice Address - Country:US
Practice Address - Phone:516-825-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-17
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant