Provider Demographics
NPI:1295716819
Name:WALLACE, ROBERT DEAN (PT)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DEAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5501 N ORACLE RD
Mailing Address - Street 2:#101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-3829
Mailing Address - Country:US
Mailing Address - Phone:520-408-9547
Mailing Address - Fax:520-293-6638
Practice Address - Street 1:5501 N ORACLE RD
Practice Address - Street 2:#101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-3829
Practice Address - Country:US
Practice Address - Phone:520-408-9547
Practice Address - Fax:520-293-6638
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ0482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ68619Medicare PIN
AZS45679Medicare UPIN