Provider Demographics
NPI:1932427101
Name:WALL, MICHAEL D (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:WALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:2720 8TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-1028
Mailing Address - Country:US
Mailing Address - Phone:515-967-0133
Mailing Address - Fax:515-967-7578
Practice Address - Street 1:2720 8TH STREET SW
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:IA
Practice Address - Zip Code:50009
Practice Address - Country:US
Practice Address - Phone:515-957-8609
Practice Address - Fax:515-957-9264
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA2069225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA719260344Medicare PIN