Healthcare Provider Details

I. General information

NPI: 1780963702
Provider Name (Legal Business Name): CHRISTOPHER BRIAN WALLS NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 07/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 HIGHWAY 28 SUITE 100
JASPER TN
37347-3695
US

IV. Provider business mailing address

980 HIGHWAY 28 SUITE 100
JASPER TN
37347-3695
US

V. Phone/Fax

Practice location:
  • Phone: 423-942-1602
  • Fax: 423-942-1265
Mailing address:
  • Phone: 423-942-1602
  • Fax: 423-942-1265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15977
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: