Provider Demographics
NPI:1780963702
Name:WALLS, CHRISTOPHER BRIAN (NP-C)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:BRIAN
Last Name:WALLS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 HIGHWAY 28
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JASPER
Mailing Address - State:TN
Mailing Address - Zip Code:37347-3695
Mailing Address - Country:US
Mailing Address - Phone:423-942-1602
Mailing Address - Fax:423-942-1265
Practice Address - Street 1:980 HIGHWAY 28
Practice Address - Street 2:SUITE 100
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3695
Practice Address - Country:US
Practice Address - Phone:423-942-1602
Practice Address - Fax:423-942-1265
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15977363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1525594Medicaid
GA003118413BMedicaid
TN1525594Medicaid