Healthcare Provider Details

I. General information

NPI: 1154838621
Provider Name (Legal Business Name): MICHEL A WALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 W LOS ANGELES AVE
MOORPARK CA
93021-1820
US

IV. Provider business mailing address

5162 VIA CAPOTE
NEWBURY PARK CA
91320-6909
US

V. Phone/Fax

Practice location:
  • Phone: 805-529-5370
  • Fax: 805-529-5370
Mailing address:
  • Phone: 805-559-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: