Healthcare Provider Details

I. General information

NPI: 1033042023
Provider Name (Legal Business Name): MICHAEL WALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 NE BURNSIDE AVE
BEND OR
97701-5122
US

IV. Provider business mailing address

18600 SE MCLOUGHLIN BLVD
MILWAUKIE OR
97267-6723
US

V. Phone/Fax

Practice location:
  • Phone: 541-797-0098
  • Fax:
Mailing address:
  • Phone: 503-946-3267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number26-CRM-5444
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: