Provider Demographics
NPI:1265891295
Name:WALLACE, JOHN (CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CRNA
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 436
Mailing Address - Street 2:
Mailing Address - City:OURAY
Mailing Address - State:CO
Mailing Address - Zip Code:81427-0436
Mailing Address - Country:US
Mailing Address - Phone:970-216-5385
Mailing Address - Fax:
Practice Address - Street 1:4351 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8259
Practice Address - Country:US
Practice Address - Phone:970-216-5385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-18
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0996269-CRNA367500000X
IL209021371367500000X
MN2355367500000X
WI10406-33367500000X
WAAP61248892367500000X
NMCRNA 01415367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered