Provider Demographics
NPI:1477657062
Name:WALL, PETER DAVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:DAVIS
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 112TH AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4509
Mailing Address - Country:US
Mailing Address - Phone:425-749-3329
Mailing Address - Fax:
Practice Address - Street 1:12333 NE 130TH LN
Practice Address - Street 2:TAN BUILDING, SUITE 240
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7467
Practice Address - Country:US
Practice Address - Phone:425-899-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043625207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine