Provider Demographics
NPI:1790968048
Name:WALLACE, STUART C (CRNA)
Entity Type:Individual
Prefix:MR
First Name:STUART
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800B BEECH AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-5416
Mailing Address - Country:US
Mailing Address - Phone:731-803-9773
Mailing Address - Fax:
Practice Address - Street 1:1800B BEECH AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-5416
Practice Address - Country:US
Practice Address - Phone:731-803-9773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13277367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered