Provider Demographics
NPI:1003057852
Name:WALLACE, MICHAEL ALAN (CNP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8210 LOUISIANA BLVD NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1761
Mailing Address - Country:US
Mailing Address - Phone:505-858-1222
Mailing Address - Fax:505-858-1224
Practice Address - Street 1:8210 LOUISIANA BLVD NE
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1761
Practice Address - Country:US
Practice Address - Phone:505-858-1222
Practice Address - Fax:505-858-1224
Is Sole Proprietor?:No
Enumeration Date:2009-03-07
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR48828363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29623341Medicaid
NMNMA100469Medicare PIN