Provider Demographics
NPI:1407244007
Name:WALL, MICHAEL ANDREW (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:WALL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:308 DOLPHIN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5266
Mailing Address - Country:US
Mailing Address - Phone:910-346-2273
Mailing Address - Fax:910-346-1907
Practice Address - Street 1:1515 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-3827
Practice Address - Country:US
Practice Address - Phone:910-592-4000
Practice Address - Fax:910-592-4007
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-05421363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant