Healthcare Provider Details

I. General information

NPI: 1902138894
Provider Name (Legal Business Name): WILLIAM COREY WALL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SPRING FOREST RD
RALEIGH NC
27616-2880
US

IV. Provider business mailing address

PO BOX 754
MORRISVILLE NC
27560-0754
US

V. Phone/Fax

Practice location:
  • Phone: 919-882-0768
  • Fax:
Mailing address:
  • Phone: 919-650-1930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number136785
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: