Provider Demographics
NPI:1114378759
Name:WALLACE, BRIAN CHARLES
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHARLES
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 1:125 W CATAWBA AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-1601
Mailing Address - Country:US
Mailing Address - Phone:704-827-3014
Mailing Address - Fax:
Practice Address - Street 1:125 W CATAWBA AVE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1601
Practice Address - Country:US
Practice Address - Phone:704-827-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant