Healthcare Provider Details

I. General information

NPI: 1174790224
Provider Name (Legal Business Name): WALLACE BLAKE MCKINNEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 V ST PSSB 2100
SACRAMENTO CA
95817-1460
US

IV. Provider business mailing address

4150 V ST PSSB 2100
SACRAMENTO CA
95817-1460
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-8571
  • Fax: 916-734-7950
Mailing address:
  • Phone: 916-734-8571
  • Fax: 916-734-7950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA105593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: