Healthcare Provider Details

I. General information

NPI: 1982996195
Provider Name (Legal Business Name): CARONIA PHILESIA WALLACE-FAIR D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARONIA PHILESIA WALLACE D.O.

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8761
US

IV. Provider business mailing address

39868 AVENUE 7 1/2
MADERA CA
93636
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-3000
  • Fax:
Mailing address:
  • Phone: 305-331-6955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number15444
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: