Healthcare Provider Details

I. General information

NPI: 1124614706
Provider Name (Legal Business Name): SHAWN MICHAEL WALLACE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 UNSER BLVD SE STE 08100
RIO RANCHO NM
87124
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-253-6100
  • Fax: 505-253-6186
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0064
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: