Provider Demographics
NPI:1275663916
Name:WALLACE, JOHN ROBERT (MSPT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MSPT
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 716
Mailing Address - Street 2:
Mailing Address - City:KILL DEVIL HILLS
Mailing Address - State:NC
Mailing Address - Zip Code:27948
Mailing Address - Country:US
Mailing Address - Phone:252-441-8580
Mailing Address - Fax:252-441-9551
Practice Address - Street 1:103 W WOODHILL DR
Practice Address - Street 2:SUITE A
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959
Practice Address - Country:US
Practice Address - Phone:252-441-8580
Practice Address - Fax:252-441-9551
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5301225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7285489Medicaid
2502023Medicare ID - Type Unspecified
S06490Medicare UPIN