John David Wallace, PA-C
Physician Assistant in East Jordan, MI. Individual provider (NPI-1).
NPI number1487909511
StatusActive
Last updated in NPPESSep 20, 2022
Details
- NPI
- 1487909511
- Entity type
- Individual (NPI-1)
- Name
- Mr. John David Wallace
- Credential
- PA-C
- Sex
- Male
- Sole proprietor
- No
- Enumeration date
- Jul 15, 2012
- Certification date
- Sep 20, 2022
- Last updated
- Sep 20, 2022
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 363A00000X | Physician Assistant | 5601006422 | MI | Yes |
Practice location
601 Bridge StEast Jordan, MI 49727-9383
Phone 231-536-2206 · Fax 231-536-7150
Mailing address
601 Bridge StEast Jordan, MI 49727-9383
Phone 231-536-2206 · Fax 231-536-7150
Other practice locations
6135 Cressy St
Indian River, MI 49749-5151
Indian River, MI 49749-5151
Phone 231-238-8908 · Fax 231-238-4419
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