MEDICARE: MRS. MICHELLE DEANNA WALL PA-C

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	103078	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2291842C	OTHER	NC	MEDICARE GROUP/ORGANIZATION PTAN
2	2759201	OTHER	NC	MEDICARE PTAN

General Provider Information

NPI Number	:	1619195302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE DEANNA WALL PA-C

Provider Business Mailing Address
First Line	:	348 N SOUTH ST
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-3532
Country	:	US
Telephone Number	:	336-786-6945
Fax Number	:

Provider Business Practice Location Address
First Line	:	348 N SOUTH ST
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-3532
Country	:	US
Telephone Number	:	336-786-6945
Fax Number	:	336-789-5782

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

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	06/08/2009

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