Provider Demographics
NPI:1376042168
Name:WALLACE, JOSHUA TAYLOR (APRN)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:TAYLOR
Last Name:WALLACE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 CINEL LOOP
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:AR
Mailing Address - Zip Code:72007-8790
Mailing Address - Country:US
Mailing Address - Phone:870-692-1906
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST # 783
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-8000
Practice Address - Fax:501-526-2000
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005500363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner