Provider Demographics
NPI:1942757497
Name:WABASH GENERAL HOSPITAL PRIMARY CARE
Entity Type:Organization
Organization Name:WABASH GENERAL HOSPITAL PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:618-262-2277
Mailing Address - Street 1:120 JAQUESS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-1211
Mailing Address - Country:US
Mailing Address - Phone:618-262-2277
Mailing Address - Fax:618-262-2281
Practice Address - Street 1:120 JAQUESS AVE
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-1211
Practice Address - Country:US
Practice Address - Phone:618-262-2277
Practice Address - Fax:618-262-2281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty