Provider Demographics
NPI:1659495919
Name:HARRISON JR, WALLACE J (DC)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:J
Last Name:HARRISON JR
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 BADGER RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-6133
Mailing Address - Country:US
Mailing Address - Phone:907-488-1885
Mailing Address - Fax:
Practice Address - Street 1:3375 BADGER RD
Practice Address - Street 2:SUITE 5
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-6133
Practice Address - Country:US
Practice Address - Phone:907-488-1885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK378111N00000X, 111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK152525Medicare ID - Type Unspecified
AK152524Medicare UPIN