Provider Demographics
NPI:1265075865
Name:TRANUM, WALLACE JR
Entity type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:
Last Name:TRANUM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 GOLDEN ARM RD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-8653
Mailing Address - Country:US
Mailing Address - Phone:407-460-7242
Mailing Address - Fax:
Practice Address - Street 1:415 GOLDEN ARM RD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-8653
Practice Address - Country:US
Practice Address - Phone:407-460-7242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-26
Last Update Date:2019-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLT655898694600172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver