Individual
FREDA ELLEN WALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
002766
GA
363AS0400X
Surgical Physician Assistant
Primary
002766
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00236158
RAILROAD MEDICARE
—
Enumeration date
06/20/2005
Last updated
10/22/2007
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