Provider Demographics
NPI:1609931393
Name:WALLACE, THEODORE WILLIAM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:WILLIAM
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6317 63RD ST W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98467-4945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CTR
Practice Address - Street 2:9040A FITZSIMMONS DR
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA100003556363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant