Provider Demographics
NPI:1467550335
Name:WALLACE, SHAUNE (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAUNE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1657 MOUNTAIN CITY HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-2809
Mailing Address - Country:US
Mailing Address - Phone:775-738-6727
Mailing Address - Fax:
Practice Address - Street 1:1657 MOUNTAIN CITY HWY STE 101
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-2809
Practice Address - Country:US
Practice Address - Phone:775-738-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV931152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000059567Medicare PIN