Provider Demographics
NPI:1902138894
Name:WALL, WILLIAM COREY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:COREY
Last Name:WALL
Suffix:
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 754
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-0754
Mailing Address - Country:US
Mailing Address - Phone:919-650-1930
Mailing Address - Fax:
Practice Address - Street 1:3100 SPRING FOREST RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-2880
Practice Address - Country:US
Practice Address - Phone:919-882-0768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC136785367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8053800Medicaid