Provider Demographics
NPI:1346528833
Name:WALLACE, CHRISTOPHER G (PA)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:G
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:12770 CIMARRON PATH
Mailing Address - Street 2:SUITE 132
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-3427
Mailing Address - Country:US
Mailing Address - Phone:210-614-3900
Mailing Address - Fax:
Practice Address - Street 1:12770 CIMARRON PATH
Practice Address - Street 2:SUITE 132
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3427
Practice Address - Country:US
Practice Address - Phone:210-614-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant