Healthcare Provider Details

I. General information

NPI: 1336131044
Provider Name (Legal Business Name): STEPHEN A WALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date: 03/23/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

2741 S 8TH AVE SUITE C
YUMA AZ
85364-7154
US

IV. Provider business mailing address

SUITE C 2741 S 8TH AVE
YUMA AZ
85364-7154
US

V. Phone/Fax

Practice location:
  • Phone: 928-726-0985
  • Fax:
Mailing address:
  • Phone: 928-726-0985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number13856
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: