Provider Demographics
NPI:1568664274
Name:WALLACE, JAMES CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:CHRISTOPHER
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CGC CHASE (WHEC-718)
Mailing Address - Street 2:FPO AP 96662-3932 32ND ST
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106
Mailing Address - Country:US
Mailing Address - Phone:858-776-7161
Mailing Address - Fax:
Practice Address - Street 1:CGC CHASE (WHEC-718) FPO AP 96662-3932 32ND ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106
Practice Address - Country:US
Practice Address - Phone:858-776-7161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB181678146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic