Basic Information
| Provider Information | |||||||||
| NPI: | 1508843335 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 COMMERCE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551254925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685904 | ||||||||
| FaxNumber: | 6519685904 | ||||||||
| Practice Location | |||||||||
| Address1: | 1661 SAINT ANTHONY AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551043733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685300 | ||||||||
| FaxNumber: | 6516460205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 07/02/2015 | ||||||||
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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 | 2083X0100X | 38367 | MN | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
No ID Information.