Provider Demographics
NPI:1932210069
Name:WALLACE, PRISCILLA JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:JANE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PRISCILLA
Other - Middle Name:W
Other - Last Name:ALEXANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:233 NE 102ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:233 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-535-8325
Practice Address - Fax:503-535-8399
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1757282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F33554Medicare UPIN
OR116720Medicare ID - Type Unspecified