Provider Demographics
NPI:1952638660
Name:STEPHEN A. WALLACE, M.D., P.C.
Entity Type:Organization
Organization Name:STEPHEN A. WALLACE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-726-0985
Mailing Address - Street 1:2741 S 8TH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7154
Mailing Address - Country:US
Mailing Address - Phone:928-726-0985
Mailing Address - Fax:928-726-9395
Practice Address - Street 1:2741 S 8TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7154
Practice Address - Country:US
Practice Address - Phone:928-726-0985
Practice Address - Fax:928-726-9395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13856207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D37799Medicare UPIN