Provider Demographics
NPI:1083083455
Name:WALLACE, AUGIE
Entity Type:Individual
Prefix:
First Name:AUGIE
Middle Name:
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 1:4312 MAIN ST APT 316
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19127-1531
Mailing Address - Country:US
Mailing Address - Phone:484-433-8208
Mailing Address - Fax:
Practice Address - Street 1:8600 W CHESTER PIKE STE 308
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2629
Practice Address - Country:US
Practice Address - Phone:484-433-8208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA28613601374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide