Provider Demographics
NPI:1760426258
Name:WALLACE, MATTHEW EDWIN (ATC, PES)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:EDWIN
Last Name:WALLACE
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Gender:M
Credentials:ATC, PES
Other - Prefix:
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Mailing Address - Street 1:2932 S 93RD PLZ
Mailing Address - Street 2:APT. 5
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2823
Mailing Address - Country:US
Mailing Address - Phone:402-990-4004
Mailing Address - Fax:402-280-3110
Practice Address - Street 1:CREIGHTON UNIUVERSITY
Practice Address - Street 2:2500 CALIFORNIA PLAZA
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68178-0001
Practice Address - Country:US
Practice Address - Phone:402-280-5563
Practice Address - Fax:402-280-3110
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE3782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer