Provider Demographics
NPI:1437356193
Name:WALLACE, AUSTIN FISHER (MD)
Entity Type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:FISHER
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1010 THREE SPRINGS BLVD
Mailing Address - Street 2:SUITE 294
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-8296
Mailing Address - Country:US
Mailing Address - Phone:970-247-4311
Mailing Address - Fax:970-764-3894
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:SUITE 294
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-247-4311
Practice Address - Fax:970-764-3894
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
HIMDR-5299207R00000X
UT7087070-1205207L00000X
CO53508207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine