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General NPI Number Information
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NPI Number | 1154838621
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Entity Type | Individual
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Provider Name | MICHEL A WALL PA-C
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Gender | Female
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Dates
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Enumeration Date | 01/05/2018
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Last Update Date | 01/05/2018
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Provider Practice Location Address
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Address Line | 35 W LOS ANGELES AVE
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City | MOORPARK
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State | CA
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Zip | 93021-1820
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Country | US
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Telephone | 805-529-5370
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Fax | 805-529-5370
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Provider Business Mailing Address
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Address Line | 5162 VIA CAPOTE
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City | NEWBURY PARK
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State | CA
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Zip | 91320-6909
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Country | US
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Telephone | 805-559-5552
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 55066
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License Number State | CA
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