Provider Demographics
NPI:1780471102
Name:WALLACE, ANTHONY NELSON JR
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:NELSON
Last Name:WALLACE
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 S 42ND ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-2910
Mailing Address - Country:US
Mailing Address - Phone:531-772-9325
Mailing Address - Fax:
Practice Address - Street 1:9001 ARBOR ST STE 206
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2066
Practice Address - Country:US
Practice Address - Phone:531-772-9325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant