Provider Demographics
NPI:1285041301
Name:CARLOS-WALLACE, CHRISTOPHER A
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:A
Last Name:CARLOS-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 1:1170 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-4980
Mailing Address - Country:US
Mailing Address - Phone:415-427-4792
Mailing Address - Fax:
Practice Address - Street 1:1170 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-4980
Practice Address - Country:US
Practice Address - Phone:415-420-4729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker