Provider Demographics
NPI:1417239591
Name:WALL, PAMELA (PA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:931 E 86TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1860
Mailing Address - Country:US
Mailing Address - Phone:317-257-1484
Mailing Address - Fax:317-257-1488
Practice Address - Street 1:931 E 86TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1860
Practice Address - Country:US
Practice Address - Phone:317-257-1484
Practice Address - Fax:317-257-1488
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10000381A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical