Healthcare Provider Details

I. General information

NPI: 1396281200
Provider Name (Legal Business Name): TREVOR J WALLACE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

988 OAK RIDGE TPKE STE 100
OAK RIDGE TN
37830-6919
US

IV. Provider business mailing address

PO BOX 306556
NASHVILLE TN
37230-6556
US

V. Phone/Fax

Practice location:
  • Phone: 865-690-4861
  • Fax: 865-483-4194
Mailing address:
  • Phone: 865-694-0062
  • Fax: 865-694-7907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8236
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6270
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: