Provider Demographics
NPI:1942247713
Name:WALLS, JASON KENDALL (PA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:KENDALL
Last Name:WALLS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4673
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-4673
Mailing Address - Country:US
Mailing Address - Phone:423-232-8301
Mailing Address - Fax:423-232-8304
Practice Address - Street 1:310 NORTH STATE AND FRANKLIN ROAD
Practice Address - Street 2:STE 103
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6063
Practice Address - Country:US
Practice Address - Phone:423-232-8301
Practice Address - Fax:423-232-8304
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000000820363AM0700X, 363AS0400X
TN820207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3661736Medicaid
TN3661736Medicare ID - Type Unspecified
TN3661736Medicaid
TN103I970004Medicare PIN