Basic Information
| Provider Information | |||||||||
| NPI: | 1386794717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DWAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA, ATC, PTA, CEAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 217 JOHN BOULDIN DR | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378011902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8658982356 | ||||||||
| FaxNumber: | 8659385264 | ||||||||
| Practice Location | |||||||||
| Address1: | 7557 DANNAHER WAY | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | POWELL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378493558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659385222 | ||||||||
| FaxNumber: | 8659385264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 06/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 3396 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 2255A2300X | 110102223 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | PENDING | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.