Provider Demographics
NPI:1821693995
Name:WALL, CONNOR THOMAS
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:THOMAS
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 1:907 VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-1567
Mailing Address - Country:US
Mailing Address - Phone:970-618-2627
Mailing Address - Fax:
Practice Address - Street 1:564 HIGHWAY 133
Practice Address - Street 2:LA FONTANA PLAZA
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623
Practice Address - Country:US
Practice Address - Phone:970-963-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0017394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist