Provider Demographics
NPI:1023283355
Name:ANTOINETTE W. WALL, M.D. PA
Entity type:Organization
Organization Name:ANTOINETTE W. WALL, M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:828-684-3949
Mailing Address - Street 1:7 GLENN BRIDGE RD
Mailing Address - Street 2:STE D
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-3322
Mailing Address - Country:US
Mailing Address - Phone:828-684-3949
Mailing Address - Fax:828-684-2330
Practice Address - Street 1:7 GLENN BRIDGE RD
Practice Address - Street 2:STE D
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-3322
Practice Address - Country:US
Practice Address - Phone:828-684-3949
Practice Address - Fax:828-684-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20857305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC85383OtherBLUE CROSS/BLUE SHIELD
NC8985383Medicaid
NC202548AMedicare PIN
NC85383OtherBLUE CROSS/BLUE SHIELD