Provider Demographics
NPI:1912361502
Name:WALLACE, ANDREW NELS (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:NELS
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E WENDOVER AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1209
Mailing Address - Country:US
Mailing Address - Phone:336-832-7840
Mailing Address - Fax:
Practice Address - Street 1:301 E WENDOVER AVE STE 111
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1209
Practice Address - Country:US
Practice Address - Phone:336-832-7840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC217732207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine