Provider Demographics
NPI:1740327139
Name:WALL, ANTHONY (NP)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 N MILLEDGE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-3806
Mailing Address - Country:US
Mailing Address - Phone:706-548-0008
Mailing Address - Fax:706-369-9673
Practice Address - Street 1:740 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5908
Practice Address - Country:US
Practice Address - Phone:706-548-0008
Practice Address - Fax:706-369-9673
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR045285363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA988504591AMedicaid
GAP96752Medicare UPIN