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General NPI Number Information
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NPI Number | 1083216949
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Entity Type | Individual
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Provider Name | BLAKE TAYLOR WALLACE DPM
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Gender | Male
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Dates
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Enumeration Date | 11/14/2020
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Last Update Date | 07/29/2024
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Provider Practice Location Address
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Address Line | 15601 N 28TH AVE STE 102
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City | PHOENIX
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State | AZ
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Zip | 85053-4061
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Country | US
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Telephone | 480-844-8218
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 32611
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City | BELFAST
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State | ME
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Zip | 04915-0219
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Country | US
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Telephone | 480-844-8218
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | POD-001117
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License Number State | AZ
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