Provider Demographics
NPI:1790859528
Name:WALLACE, CHRISTOPHER SHAWN (OD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:SHAWN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8624 202ND ST SW
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-6644
Mailing Address - Country:US
Mailing Address - Phone:206-419-7400
Mailing Address - Fax:
Practice Address - Street 1:8745 GLACIER HWY
Practice Address - Street 2:SPACE 426
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-8029
Practice Address - Country:US
Practice Address - Phone:907-796-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK 201152W00000X
WAOD3752WA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD 5342Medicaid