Provider Demographics
NPI:1962071050
Name:WALL, JAMES RYAN (DPT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RYAN
Last Name:WALL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-206-4158
Mailing Address - Fax:
Practice Address - Street 1:1211 S GLOSTER ST STE C
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6548
Practice Address - Country:US
Practice Address - Phone:662-432-1523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT7109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist