Provider Demographics
NPI:1013124908
Name:WALLACE, JAMES DORAN (PA,DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DORAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PA,DC
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Mailing Address - Street 1:8948 SALMON FALLS DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-1923
Mailing Address - Country:US
Mailing Address - Phone:916-765-3785
Mailing Address - Fax:916-361-9869
Practice Address - Street 1:1650 LEAD HILL BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3061
Practice Address - Country:US
Practice Address - Phone:916-765-3785
Practice Address - Fax:916-361-9869
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2009-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA14039363AM0700X
CA12087111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No111NX0800XChiropractic ProvidersChiropractorOrthopedic