Basic Information
| Provider Information | |||||||||
| NPI: | 1588760391 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | RANDY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 21ST AVE S | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372124354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152690652 | ||||||||
| FaxNumber: | 6152690135 | ||||||||
| Practice Location | |||||||||
| Address1: | 651 DUNLOP LN | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370405015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315021370 | ||||||||
| FaxNumber: | 6152690135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 08/04/2011 | ||||||||
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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 | 363A00000X | 446 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00367293 | 01 | TN | RAILROAD MEDICARE | OTHER |