Provider Demographics
NPI:1255448650
Name:NEWKIRK, WALLACE ALLYN (MD)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:ALLYN
Last Name:NEWKIRK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 TENTH AVE SW
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:WA
Mailing Address - Zip Code:98848
Mailing Address - Country:US
Mailing Address - Phone:509-787-3503
Mailing Address - Fax:509-787-1361
Practice Address - Street 1:908 TENTH AVE SW
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:WA
Practice Address - Zip Code:98848
Practice Address - Country:US
Practice Address - Phone:509-787-3503
Practice Address - Fax:509-787-1361
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8429839Medicaid
WA0199849OtherDEPT OF LABOR & INDUSTRIE
I25332Medicare UPIN
8855473Medicare ID - Type Unspecified