Provider Demographics
NPI:1497729909
Name:WALLACE, NICHOLE G (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:G
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUZANNE
Other - Middle Name:NICHOLE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:303-493-7000
Mailing Address - Fax:
Practice Address - Street 1:13123 E 16TH AVE
Practice Address - Street 2:B390
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7106
Practice Address - Country:US
Practice Address - Phone:303-864-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR00541492080C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200020480BMedicaid
OK200020480BMedicaid
I02718Medicare UPIN