Provider Demographics
NPI:1427640283
Name:WALL, LARRY
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:WALL
Suffix:
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 1:7523 BUCHANAN ST APT 242
Mailing Address - Street 2:
Mailing Address - City:LANDOVER HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20784-2389
Mailing Address - Country:US
Mailing Address - Phone:240-901-0484
Mailing Address - Fax:
Practice Address - Street 1:7523 BUCHANAN STREET
Practice Address - Street 2:APT 242
Practice Address - City:LANDOVER HILLS
Practice Address - State:MD
Practice Address - Zip Code:20784
Practice Address - Country:US
Practice Address - Phone:240-901-0484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant