Basic Information
| Provider Information | |||||||||
| NPI: | 1306301254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 S 16TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685023704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024818566 | ||||||||
| FaxNumber: | 4024818805 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 S 16TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685023704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024818566 | ||||||||
| FaxNumber: | 4024818805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2019 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 095108 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2323 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.