Provider Demographics
NPI:1588671291
Name:NUNLEY, WALLACE C (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:C
Last Name:NUNLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2955 IVY RD
Practice Address - Street 2:STE 304
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-9353
Practice Address - Country:US
Practice Address - Phone:434-243-2743
Practice Address - Fax:434-982-5109
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38155207V00000X
VA0101027468207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1588671291Medicaid
NC8963646Medicaid
NC2157266Medicare PIN
NCB10117Medicare UPIN
NC2157265Medicare ID - Type Unspecified
VA1588671291Medicaid