Provider Demographics
NPI:1932770005
Name:WALL, JACOB B (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:B
Last Name:WALL
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:415 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5003
Practice Address - Country:US
Practice Address - Phone:812-333-7433
Practice Address - Fax:812-333-7435
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2024-01-30
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Provider Licenses
StateLicense IDTaxonomies
IN10003433A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical