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NPI Code Detail

MEDICARE: KENDALL VAN DE WALLE PA

MEDICARE: KENDALL VAN DE WALLE 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
1363A00000XPhysician AssistantPA18424TX

General Provider Information

NPI Number : 1720836125
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENDALL VAN DE WALLE PA
Provider Business Mailing Address
First Line : PO BOX 844658
Second Line :
City : DALLAS
State : TX
Zip : 75284-4658
Country : US
Telephone Number : 254-724-2111
Fax Number :
Provider Business Practice Location Address
First Line : 800 SCOTT AND WHITE DR
Second Line :
City : COLLEGE STATION
State : TX
Zip : 77845-6440
Country : US
Telephone Number : 979-207-4000
Fax Number : 979-207-4562
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/09/2024
Last Update Date : 02/17/2026

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Directions to “ KENDALL VAN DE WALLE PA” Practice Location

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