Provider Demographics
NPI:1386292357
Name:WALL, KEVIN ALAN (FNP)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ALAN
Last Name:WALL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 STATE ROUTE 41
Mailing Address - Street 2:
Mailing Address - City:CINCINNATUS
Mailing Address - State:NY
Mailing Address - Zip Code:13040-2215
Mailing Address - Country:US
Mailing Address - Phone:607-345-9992
Mailing Address - Fax:
Practice Address - Street 1:200 FRONT ST STE C
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1559
Practice Address - Country:US
Practice Address - Phone:607-239-5694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344995363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily