Provider Demographics
NPI:1386794717
Name:WALL, MICHAEL DWAYNE (PA, ATC, PTA, CEAS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DWAYNE
Last Name:WALL
Suffix:
Gender:M
Credentials:PA, ATC, PTA, CEAS
Other - Prefix:
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Mailing Address - Street 1:217 JOHN BOULDIN DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-1902
Mailing Address - Country:US
Mailing Address - Phone:865-898-2356
Mailing Address - Fax:865-938-5264
Practice Address - Street 1:7557 DANNAHER WAY
Practice Address - Street 2:SUITE 230
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3558
Practice Address - Country:US
Practice Address - Phone:865-938-5222
Practice Address - Fax:865-938-5264
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2010-06-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN3396225200000X
TN1101022232255A2300X
TNPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer