Provider Demographics
NPI:1366871972
Name:WALL, TREVOR G (PA-C)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:G
Last Name:WALL
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 1:1 MERCADO ST
Mailing Address - Street 2:STE 202
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7306
Mailing Address - Country:US
Mailing Address - Phone:970-247-5362
Mailing Address - Fax:970-259-6045
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:STE 202
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7306
Practice Address - Country:US
Practice Address - Phone:970-247-5362
Practice Address - Fax:970-259-6045
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2013-0074363A00000X
COPA. 0003986363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57729301Medicaid