Provider Demographics
NPI:1255972568
Name:WALLACE, ROBERT BOWMAN (DPT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BOWMAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601791
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1791
Mailing Address - Country:US
Mailing Address - Phone:704-323-3611
Mailing Address - Fax:
Practice Address - Street 1:5935 CARNEGIE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-4672
Practice Address - Country:US
Practice Address - Phone:043-232-5007
Practice Address - Fax:704-323-3993
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP19188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist