Provider Demographics
NPI:1508843335
Name:WALL, KEVIN S
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:WALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5904
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:1661 SAINT ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3733
Practice Address - Country:US
Practice Address - Phone:651-968-5300
Practice Address - Fax:651-646-0205
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN383672083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine