Provider Demographics
NPI:1790017028
Name:WALLACE, BRIAN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:EDWARD
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 1:400 E PIONEER AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3255
Mailing Address - Country:US
Mailing Address - Phone:253-445-5828
Mailing Address - Fax:
Practice Address - Street 1:400 E PIONEER AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3255
Practice Address - Country:US
Practice Address - Phone:253-445-5828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 60120035207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology