Healthcare Provider Details

I. General information

NPI: 1952638660
Provider Name (Legal Business Name): STEPHEN A. WALLACE, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 928-726-0985
  • Fax: 928-726-9395
Mailing address:
  • Phone: 928-726-0985
  • Fax: 928-726-9395

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: BECKY L WALLACE
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 928-726-0985