Basic Information
| Provider Information | |||||||||
| NPI: | 1790712792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | STE 310 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | STE 210 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 04/24/2014 | ||||||||
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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 | 207X00000X | 36177 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 36177 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5550830008 | 01 | AZ | MEDICARE NSC SWV | OTHER | 5550830009 | 01 | AZ | MEDICARE NSC AZ NORTH | OTHER | 5550830006 | 01 | AZ | MEDICARE NSC ANTHEM | OTHER | P00618125 | 01 | AZ | RR MEDICARE | OTHER | 5550830001 | 01 | AZ | MEDICARE NSC SCW | OTHER | 159666 | 05 | AZ | MEDICAID | 5550830003 | 01 | AZ | MEDICARE NSC PEORIA | OTHER | 5550830004 | 01 | AZ | MEDICARE NSC PV | OTHER | 5550830007 | 01 | AZ | MEDICARE NSC DV | OTHER | 5550830010 | 01 | AZ | MEDICARE NSC GILBERT | OTHER |