Provider Demographics
NPI:1457515587
Name:WALLACE, STEVEN EARL (RPA)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:EARL
Last Name:WALLACE
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 RIDGERUN RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:CA
Mailing Address - Zip Code:95971-9380
Mailing Address - Country:US
Mailing Address - Phone:530-283-3504
Mailing Address - Fax:530-283-1838
Practice Address - Street 1:1065 BUCKS LAKE RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:CA
Practice Address - Zip Code:95971-9507
Practice Address - Country:US
Practice Address - Phone:530-283-7155
Practice Address - Fax:530-283-1838
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
243U00000X246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical