Provider Demographics
NPI:1679692511
Name:STURGIS, WALLY (PA)
Entity type:Individual
Prefix:
First Name:WALLY
Middle Name:
Last Name:STURGIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 HIGH VALLEY ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:NC
Mailing Address - Zip Code:28701-9726
Mailing Address - Country:US
Mailing Address - Phone:828-683-4437
Mailing Address - Fax:
Practice Address - Street 1:201 TABERNACLE RD
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-2526
Practice Address - Country:US
Practice Address - Phone:828-669-3496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100651363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC100651OtherMEDICAL BOARD NUMBER