Provider Demographics
NPI:1659352052
Name:HORNE, WALLACE JENNINGS (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:JENNINGS
Last Name:HORNE
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 1706
Mailing Address - Street 2:800 TILGHMAN DRIVE
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28335-1706
Mailing Address - Country:US
Mailing Address - Phone:910-694-1000
Mailing Address - Fax:910-891-6030
Practice Address - Street 1:800 TILGHMAN DR
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-5510
Practice Address - Country:US
Practice Address - Phone:910-694-1000
Practice Address - Fax:910-891-6030
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034381207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5869862Medicaid
VA11000835Medicare ID - Type Unspecified
VA5869862Medicaid