Basic Information
| Provider Information | |||||||||
| NPI: | 1578067021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 FIELDSTONE DR | ||||||||
| Address2: | |||||||||
| City: | EAST SANDWICH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025371359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083146235 | ||||||||
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| Practice Location | |||||||||
| Address1: | UVMMC 111 COLCHESTER AVENUE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028472345 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2018 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.