Provider Demographics
NPI:1972573939
Name:WALL, WILLIAM GEORGE II (CRNA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GEORGE
Last Name:WALL
Suffix:II
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-0388
Mailing Address - Country:US
Mailing Address - Phone:316-281-3700
Mailing Address - Fax:316-282-4322
Practice Address - Street 1:2103 SILVA LANE
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270
Practice Address - Country:US
Practice Address - Phone:660-263-1266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO150584367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO913871505Medicaid
MOP00301756Medicare PIN
MO825344872Medicare PIN