Individual
VAN WALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2817 REILLY ST, FORT BRAGG, NC 28310
(910) 907-6000
Mailing address
9040 FITZSIMMONS DR, JOINT BASE LEWIS MCCHORD, WA 98431-1000
(253) 968-2997
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
2018-00185
NC
Other
Enumeration date
04/18/2014
Last updated
07/18/2018
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