Dr. Brent E Wallace, MD
Family Medicine in Roy, UT. Individual provider (NPI-1).
NPI number1124136221
StatusActive
Last updated in NPPESJul 10, 2008
Details
- NPI
- 1124136221
- Entity type
- Individual (NPI-1)
- Name
- Dr. Brent E Wallace
- Credential
- MD
- Sex
- Male
- Sole proprietor
- No
- Enumeration date
- Aug 28, 2006
- Last updated
- Jul 10, 2008
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 207Q00000X | Family Medicine | 771610101205 | UT | Yes |
Practice location
1915 W 5950 SRoy, UT 84067-1454
Phone 801-387-8100
Mailing address
Po Box 27128Salt Lake City, UT 84127-0128
Phone 801-387-8100
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