Provider Demographics
NPI:1497894117
Name:WALL, PHILLY MARIE (PA)
Entity Type:Individual
Prefix:
First Name:PHILLY
Middle Name:MARIE
Last Name:WALL
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 1:830 4TH AVE SE STE 1
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2445
Mailing Address - Country:US
Mailing Address - Phone:319-363-8121
Mailing Address - Fax:
Practice Address - Street 1:830 4TH AVE SE STE 1
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2445
Practice Address - Country:US
Practice Address - Phone:402-650-6765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0188946Medicaid
IA421466508OtherTAX ID NUMBER
IA49614Medicare ID - Type UnspecifiedMEDICARE PART B
IA421466508OtherTAX ID NUMBER