Provider Demographics
NPI:1205889326
Name:HALL, WILLIAM CHARLES ANDREW (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CHARLES ANDREW
Last Name:HALL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 N HARBOR BLVD STE 35000
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2141 N HARBOR BLVD
Practice Address - Street 2:SUITE 35000
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835
Practice Address - Country:US
Practice Address - Phone:714-626-8630
Practice Address - Fax:714-626-8659
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002096363AS0400X
CAPA23284363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085002096OtherBLUE CROSS/BLUE SHIELD PROVIDER NUMBER
IL085002096OtherSTATE LICENSE
IL1032380001Medicare NSC
IL085002096OtherBLUE CROSS/BLUE SHIELD PROVIDER NUMBER