Provider Demographics
NPI:1194029777
Name:WALLACE, MICHAEL T (ARNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:WALLACE
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 953
Mailing Address - Street 2:
Mailing Address - City:COLEMAN
Mailing Address - State:FL
Mailing Address - Zip Code:33521-0953
Mailing Address - Country:US
Mailing Address - Phone:352-254-0153
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:352-529-7314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7139-33363LA2200X
FLARNP2975042363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007980600Medicaid
WIMW4048559OtherDEA
FLGC190YMedicare PIN