Healthcare Provider Details

I. General information

NPI: 1063417608
Provider Name (Legal Business Name): FREDA ELLEN WALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FREDA ELLEN SIMS

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 PEACHTREE RD NE STE 645
ATLANTA GA
30309-1476
US

IV. Provider business mailing address

2001 PEACHTREE RD NE STE 645
ATLANTA GA
30309-1476
US

V. Phone/Fax

Practice location:
  • Phone: 404-350-0106
  • Fax: 404-350-0176
Mailing address:
  • Phone: 404-350-0106
  • Fax: 404-350-0176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002766
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number002766
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: