Healthcare Provider Details

I. General information

NPI: 1427221662
Provider Name (Legal Business Name): JASON DAVID WALLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST 6 DULLES
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

3400 SPRUCE ST 6 DULLES
PHILADELPHIA PA
19104
US

V. Phone/Fax

Practice location:
  • Phone: 215-349-8310
  • Fax:
Mailing address:
  • Phone: 215-349-8310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD-451432
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: