Basic Information
| Provider Information | |||||||||
| NPI: | 1861900797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 SOUTH MOPAC EXPRESSWAY | ||||||||
| Address2: | APT 1521 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654320698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 W BEN WHITE BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787046903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124472211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2018 | ||||||||
| LastUpdateDate: | 01/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA11719 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.