Provider Demographics
NPI:1245348358
Name:WALL, TAMMY R (PA-C)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:R
Last Name:WALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4254 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-2469
Mailing Address - Country:US
Mailing Address - Phone:361-853-4191
Mailing Address - Fax:
Practice Address - Street 1:4254 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-2469
Practice Address - Country:US
Practice Address - Phone:361-853-4191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2025-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03796363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q19148Medicare UPIN
TX8B9744Medicare ID - Type Unspecified