NPIMap

Individual provider Active NPI

Michael Dwayne Wall, PA, ATC, PTA, CEAS

  • Physician Assistant
  • Powell, TN
National Provider Identifier
1386794717
Registry record updated Jun 14, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PENDING Issued in TN
Practice address
7557 Dannaher Way
Suite 230
Powell, TN 37849-3558
Phone
(865) 938-5222
Fax
(865) 938-5264
NPI assigned
Jan 10, 2007
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 14, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapy Assistant 225200000X 3396 TN
Athletic Trainer 2255A2300X 110102223 TN
Physician Assistant 363A00000X PENDING TN Primary

Addresses

Primary practice location

7557 Dannaher Way
Suite 230
Powell, TN 37849-3558

Mailing address

217 John Bouldin Dr
Maryville, TN 37801-1902
Phone (865) 898-2356

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20110216000396 TN Practitioner - Physician Assistant 2466632955 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2009
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Champion Physical Therapy LLC HallsGroup PAC ID 1355416306, shared by 4 NPIs, 277 clinicians

Practice addresses (Care Compare)

121 N Calderwood St
Alcoa, TN 37701-2109
Phone (865) 336-9188

362 High St
Maryville, TN 37804-5835
Phone (865) 413-1589

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
110102223TNMDAthletic Trainer
PENDINGTNMDSpeech-Language Pathologist

Practice roles

OrganizationSpecialtyStatusNew patients
Athens Physicians Practice LLC CurrentSince Jul 1, 2012 Accepting new patients
Athens Physicians Practice LLC Past Accepting new patients
Foothills Language and Feeding, LLC Past Accepting new patients
Blount Hospitalists PC Past Accepting new patients
Abercrombie Radiological Consultants Inc Past Accepting new patients
Tennessee Urology Associates, PLLC Past Accepting new patients

Locations

719 Cook Dr
Ste 104
Athens, TN 37303
Phone (423) 745-9770

711 Cook Dr
Ste 200
Athens, TN 37303
Phone (423) 507-8369

711 Cook Dr
Ste 100
Athens, TN 37303
Phone (423) 744-7585

872 Highway 411 N
Unit G
Etowah, TN 37331
Phone (423) 744-7585

Organizations & group practices 11

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 2

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168387200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1276473600000",
    "number": "1386794717",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "217 JOHN BOULDIN DR",
            "city": "MARYVILLE",
            "state": "TN",
            "postal_code": "378011902",
            "telephone_number": "865-898-2356",
            "fax_number": "865-938-5264"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7557 DANNAHER WAY",
            "address_2": "SUITE 230",
            "city": "POWELL",
            "state": "TN",
            "postal_code": "378493558",
            "telephone_number": "865-938-5222",
            "fax_number": "865-938-5264"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALL",
        "first_name": "MICHAEL",
        "middle_name": "DWAYNE",
        "name_prefix": "Mr.",
        "credential": "PA, ATC, PTA, CEAS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-01-10",
        "last_updated": "2010-06-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "TN",
            "license": "3396",
            "primary": false
        },
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "TN",
            "license": "110102223",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TN",
            "license": "PENDING",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Powell, TN

Sources for this page

Verify at the official NPI Registry.