Provider Demographics
NPI:1902855612
Name:WALLACE, ANNMARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANNMARIE
Other - Middle Name:
Other - Last Name:MUNTEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 650426
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0426
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:7700 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3902
Practice Address - Country:US
Practice Address - Phone:210-575-4076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-258973367500000X
TX733121367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH100153OtherEMPLOYER KAISER GROUP #
OH120766OtherKAISER PERMANENTE INDV #
OH34-0891295OtherEMPLOYER FEDERAL TAX ID #
OH7091249Medicaid
OH000000220486OtherANTHEM BCBS INDV #
TX89594UOtherBCBS
OH730559OtherBUCKEYE COMMUNITY HLTH PL
TX182095303Medicaid
OH2274926Medicaid
OH2080224OtherUNITED HEALTHCARE GROUP #
OH120766OtherKAISER PERMANENTE INDV #
TX89594UOtherBCBS
OH430070309Medicare ID - Type UnspecifiedRAILROAD MEDICARE INDV #
TX182095303Medicaid
OH2080224OtherUNITED HEALTHCARE GROUP #