Healthcare Provider Details

I. General information

NPI: 1427095280
Provider Name (Legal Business Name): ROBERT BRIAN WALL NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 GLEN COVE DR
ROCKPORT ME
04856-4240
US

IV. Provider business mailing address

6 GLEN COVE DR
ROCKPORT ME
04856-4240
US

V. Phone/Fax

Practice location:
  • Phone: 207-596-8215
  • Fax:
Mailing address:
  • Phone: 207-596-8215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number258647
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number258647
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number258647
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP131013
License Number StateME
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP131013
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: