Provider Demographics
NPI:1649477407
Name:FALLIN, WILLIAM MATTHEW (PA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MATTHEW
Last Name:FALLIN
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 1:180 MEDICAL ST
Mailing Address - Street 2:
Mailing Address - City:SNEAD
Mailing Address - State:AL
Mailing Address - Zip Code:35952-6468
Mailing Address - Country:US
Mailing Address - Phone:205-466-7114
Mailing Address - Fax:
Practice Address - Street 1:180 MEDICAL STREET
Practice Address - Street 2:
Practice Address - City:SNEAD
Practice Address - State:AL
Practice Address - Zip Code:35952
Practice Address - Country:US
Practice Address - Phone:205-466-7114
Practice Address - Fax:205-466-3350
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-527363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009910399Medicaid
AL541003888Medicaid
ALF020OtherSNEAD MEDICARE GROUP #
AL541003888Medicaid