Provider Demographics
NPI:1619195302
Name:WALL, MICHELLE DEANNA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DEANNA
Last Name:WALL
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 1:348 N SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-3532
Mailing Address - Country:US
Mailing Address - Phone:336-786-6945
Mailing Address - Fax:
Practice Address - Street 1:348 N SOUTH ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3532
Practice Address - Country:US
Practice Address - Phone:336-786-6945
Practice Address - Fax:336-789-5782
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103078363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2291842COtherMEDICARE GROUP/ORGANIZATION PTAN
NC2759201OtherMEDICARE PTAN