Provider Demographics
NPI:1700812757
Name:WALL, WENDELL A (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:A
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 HIGHWAY 59 S
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-4331
Mailing Address - Country:US
Mailing Address - Phone:218-681-4747
Mailing Address - Fax:218-683-2595
Practice Address - Street 1:1720 HIGHWAY 59 S
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-4331
Practice Address - Country:US
Practice Address - Phone:218-681-4747
Practice Address - Fax:218-683-2595
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28024207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN068G5WAOtherMNBS #
MN002767700Medicaid
MN14419Medicaid
ND2395OtherNDBS #
ND20522OtherNDBS #
MN769233OtherAMERICA'S PPO/ARAZ #
MNDA9021015637OtherPREFERRED ONE #
MNHP19559OtherHEALTHPARTNERS #
MN142078OtherUCARE #
NDND200109OtherLHS #
ND0701809OtherMEDICA #
MN24343OtherNDBS #
ND45G58WAOtherMNBS #
MN0703790OtherMEDICA #
ND160021461Medicare ID - Type UnspecifiedRR MEDICARE #
ND20522Medicare ID - Type UnspecifiedND MEDICARE #
MNDA9021015637OtherPREFERRED ONE #
MN142078OtherUCARE #
ND160054568Medicare ID - Type UnspecifiedRR MEDICARE #
MN002767700Medicaid