Provider Demographics
NPI:1770199838
Name:WALL, CHRISTOPHER (PTA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 HACIENDA
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2835
Mailing Address - Country:US
Mailing Address - Phone:321-456-7883
Mailing Address - Fax:
Practice Address - Street 1:130 HACIENDA
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-2835
Practice Address - Country:US
Practice Address - Phone:321-456-7883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30410225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant