Provider Demographics
NPI:1720007156
Name:WALLACE, ROBERT ERIC (APN)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ERIC
Last Name:WALLACE
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY CIR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-1367
Mailing Address - Country:US
Mailing Address - Phone:309-298-1888
Mailing Address - Fax:309-298-2188
Practice Address - Street 1:1 UNIVERSITY CIR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-1367
Practice Address - Country:US
Practice Address - Phone:309-298-1888
Practice Address - Fax:309-298-2188
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily