Provider Demographics
NPI:1679839534
Name:WALLACE, HAILY (MD)
Entity Type:Individual
Prefix:
First Name:HAILY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HAILY
Other - Middle Name:CATHARINE
Other - Last Name:LEE-WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:402 E MIEL DE LUNA AVE
Practice Address - Street 2:PMG AT DR DAN C TRIGG MEMORIAL HOSPITAL
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-3828
Practice Address - Country:US
Practice Address - Phone:575-461-7100
Practice Address - Fax:575-461-7101
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0895207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program