Provider Demographics
NPI:1720315336
Name:WALLACE, ROBERT (PA, NP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PA, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 52ND ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1809
Mailing Address - Country:US
Mailing Address - Phone:510-238-0121
Mailing Address - Fax:510-238-0121
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3022
Practice Address - Fax:510-428-3022
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20650363A00000X
CA19738363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant