MEDICARE: PHILLY MARIE WALL P.A.

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	001778	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497894117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLY MARIE WALL P.A.

Provider Business Mailing Address
First Line	:	830 4TH AVE SE STE 1
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52403-2445
Country	:	US
Telephone Number	:	319-363-8121
Fax Number	:

Provider Business Practice Location Address
First Line	:	830 4TH AVE SE STE 1
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52403-2445
Country	:	US
Telephone Number	:	319-363-8121
Fax Number	:

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

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	06/23/2026

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