MEDICARE: PAMELA WALL PA

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	363AM0700X	Medical Physician Assistant	10000381A	IN

General Provider Information

NPI Number	:	1417239591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA WALL PA

Provider Business Mailing Address
First Line	:	931 E 86TH ST
Second Line	:	SUITE 104
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1860
Country	:	US
Telephone Number	:	317-257-1484
Fax Number	:	317-257-1488

Provider Business Practice Location Address
First Line	:	931 E 86TH ST
Second Line	:	SUITE 104
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1860
Country	:	US
Telephone Number	:	317-257-1484
Fax Number	:	317-257-1488

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

Provider Enumeration Date	:	09/14/2011
Last Update Date	:	09/15/2014

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Directions to “ PAMELA WALL PA” Practice Location

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