Provider Demographics
NPI:1023066354
Name:WALLACE, JAMIE RUSSELLE (MD)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:RUSSELLE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10752 N 89TH PL
Mailing Address - Street 2:#126
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260
Mailing Address - Country:US
Mailing Address - Phone:480-860-1161
Mailing Address - Fax:480-860-6561
Practice Address - Street 1:10752 N 89TH PL
Practice Address - Street 2:#126
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260
Practice Address - Country:US
Practice Address - Phone:480-860-1161
Practice Address - Fax:480-860-6561
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12810208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ226143-001Medicaid