Provider Demographics
NPI:1942307855
Name:WALL, MONICA JAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:JAYNE
Last Name:WALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 530245
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89053-0245
Mailing Address - Country:US
Mailing Address - Phone:702-614-4476
Mailing Address - Fax:702-914-7644
Practice Address - Street 1:3031 W HORIZON RIDGE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3809
Practice Address - Country:US
Practice Address - Phone:702-614-4476
Practice Address - Fax:702-914-7644
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV8291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002422Medicaid
NV110182576OtherRAILROAD MEDICARE
NVG47830Medicare UPIN