Individual
MRS. MICHELLE DEANNA WALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
348 N SOUTH ST, MOUNT AIRY, NC 27030-3532
(336) 786-6945
(336) 789-5782
Mailing address
348 N SOUTH ST, MOUNT AIRY, NC 27030-3532
(336) 786-6945
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
103078
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2291842C
MEDICARE GROUP/ORGANIZATION PTAN
NC
01
—
2759201
MEDICARE PTAN
NC
Enumeration date
04/20/2007
Last updated
06/08/2009
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