Provider Demographics
NPI:1609821156
Name:WALLACE, JONATHAN O (CRNA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:O
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 934369
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-0001
Mailing Address - Country:US
Mailing Address - Phone:800-897-6169
Mailing Address - Fax:800-897-6170
Practice Address - Street 1:5 MOBILE INFIRMARY CIR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3513
Practice Address - Country:US
Practice Address - Phone:251-432-4497
Practice Address - Fax:251-432-0577
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL1101813367500000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALQ67621Medicare UPIN