Provider Demographics
NPI:1134093099
Name:WALL, RICHARD ALAN II
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:WALL
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 TIDWELL RD
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-4172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 HOSPITAL DR STE 230
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3838
Practice Address - Country:US
Practice Address - Phone:478-751-0332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN314437363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner