Provider Demographics
NPI:1003339094
Name:WALLACE, TREVOR DEWITT
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:DEWITT
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 EVA KENNEDY RD APT 8
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3008
Mailing Address - Country:US
Mailing Address - Phone:770-369-1497
Mailing Address - Fax:
Practice Address - Street 1:571 EVA KENNEDY RD APT 8
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3008
Practice Address - Country:US
Practice Address - Phone:770-369-1497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty