Provider Demographics
NPI:1912014838
Name:WALLACE, JAMES KENNETH (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:KENNETH
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 1:195 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785-1201
Mailing Address - Country:US
Mailing Address - Phone:903-683-2676
Mailing Address - Fax:903-315-5301
Practice Address - Street 1:703 E MARSHALL AVE
Practice Address - Street 2:SUITE 2000
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5500
Practice Address - Country:US
Practice Address - Phone:903-315-5300
Practice Address - Fax:903-315-5301
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228579367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87813NMedicare ID - Type Unspecified