Healthcare Provider Details

I. General information

NPI: 1881923647
Provider Name (Legal Business Name): WALLACE M SHERIDAN JR PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5415 LOST LN
SAN ANTONIO TX
78238-2754
US

IV. Provider business mailing address

5415 LOST LN
SAN ANTONIO TX
78238-2754
US

V. Phone/Fax

Practice location:
  • Phone: 210-448-9111
  • Fax: 210-308-9595
Mailing address:
  • Phone: 210-448-9111
  • Fax: 210-308-9595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1096907
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: