Provider Demographics
NPI:1922395375
Name:WALLACE, JOHN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 SE SUNNYSIDE RD
Mailing Address - Street 2:300
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5738
Mailing Address - Country:US
Mailing Address - Phone:503-659-5115
Mailing Address - Fax:
Practice Address - Street 1:17891 SW TUALATIN VALLEY HWY
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97006-4448
Practice Address - Country:US
Practice Address - Phone:503-591-7027
Practice Address - Fax:503-642-9435
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-10135632237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist