Healthcare Provider Details

I. General information

NPI: 1386091015
Provider Name (Legal Business Name): MATTHEW FRENCH WALLACE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 NE 134TH ST STE 205
VANCOUVER WA
98686-3032
US

IV. Provider business mailing address

1100 3RD ST
TILLAMOOK OR
97141-3402
US

V. Phone/Fax

Practice location:
  • Phone: 360-576-5060
  • Fax: 360-576-1133
Mailing address:
  • Phone: 503-842-5546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60923310
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA184421
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: