Provider Demographics
NPI:1568037612
Name:WALLS, ALEXIS MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MARIE
Last Name:WALLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 BREEZY WAY
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-6513
Mailing Address - Country:US
Mailing Address - Phone:570-903-5398
Mailing Address - Fax:
Practice Address - Street 1:590 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-9195
Practice Address - Country:US
Practice Address - Phone:717-274-0421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty