Provider Demographics
NPI:1346379161
Name:WALLACE, JOHN G (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:17515 N PARK PL N
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-4803
Mailing Address - Country:US
Mailing Address - Phone:206-533-2158
Mailing Address - Fax:206-533-2158
Practice Address - Street 1:17515 N PARK PL N
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-4803
Practice Address - Country:US
Practice Address - Phone:206-533-2158
Practice Address - Fax:206-533-2158
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WA000089642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAO5879Medicare UPIN