MEDICARE: SARAH ELIZABETH WALLS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-06793	NC

General Provider Information

NPI Number	:	1356766810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH ELIZABETH WALLS

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7210 VILLAGE MEDICAL CIR
Second Line	:	STE 310
City	:	CLEMMONS
State	:	NC
Zip	:	27012-8029
Country	:	US
Telephone Number	:	336-277-4075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2014
Last Update Date	:	06/13/2022

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