Provider Demographics
NPI:1063417608
Name:WALL, FREDA ELLEN (PA-C)
Entity type:Individual
Prefix:
First Name:FREDA
Middle Name:ELLEN
Last Name:WALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:FREDA
Other - Middle Name:ELLEN
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2001 PEACHTREE RD NE
Mailing Address - Street 2:STE 645
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1476
Mailing Address - Country:US
Mailing Address - Phone:404-350-0106
Mailing Address - Fax:404-350-0176
Practice Address - Street 1:2001 PEACHTREE RD NE
Practice Address - Street 2:STE 645
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1476
Practice Address - Country:US
Practice Address - Phone:404-350-0106
Practice Address - Fax:404-350-0176
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002766363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00236158OtherRAILROAD MEDICARE
P00236158OtherRAILROAD MEDICARE
97WCFJTMedicare ID - Type Unspecified