Provider Demographics
NPI:1891793923
Name:WALLACE, ANTHONY PAUL (PT)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:PAUL
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5255 EL CAMINO REAL STE C
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-3351
Mailing Address - Country:US
Mailing Address - Phone:805-237-0272
Mailing Address - Fax:805-237-2416
Practice Address - Street 1:5255 EL CAMINO REAL STE C
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-3351
Practice Address - Country:US
Practice Address - Phone:805-237-0272
Practice Address - Fax:805-237-2416
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT10294AMedicare ID - Type Unspecified