Provider Demographics
NPI:1194743997
Name:WALL, CAROLE (PA)
Entity type:Individual
Prefix:
First Name:CAROLE
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 ROLLING LN
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19055-1112
Mailing Address - Country:US
Mailing Address - Phone:215-946-8111
Mailing Address - Fax:
Practice Address - Street 1:49 ROLLING LN
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:PA
Practice Address - Zip Code:19055-1112
Practice Address - Country:US
Practice Address - Phone:215-946-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002364-L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant