Provider Demographics
NPI:1689877102
Name:WALLACE, WESLEY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:ROBERT
Last Name:WALLACE
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 1:18 CANOE LN
Mailing Address - Street 2:
Mailing Address - City:MOULTONBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03254-4941
Mailing Address - Country:US
Mailing Address - Phone:603-253-9046
Mailing Address - Fax:
Practice Address - Street 1:21 E HOLLIS ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-2928
Practice Address - Country:US
Practice Address - Phone:603-577-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH5806207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery