Healthcare Provider Details

I. General information

NPI: 1780597534
Provider Name (Legal Business Name): ANTONIO MARQUEZ WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 N COOPER ST
ARLINGTON TX
76011-3639
US

IV. Provider business mailing address

2250 SARA JANE PKWY APT 10305
GRAND PRAIRIE TX
75052-4922
US

V. Phone/Fax

Practice location:
  • Phone: 817-385-9185
  • Fax:
Mailing address:
  • Phone: 601-678-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2179103
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: