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General NPI Number Information
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NPI Number | 1194029777
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Entity Type | Individual
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Provider Name | MICHAEL T WALLACE ARNP
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Gender | Male
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Dates
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Enumeration Date | 12/22/2010
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 9900 BREN RD E
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City | MINNETONKA
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State | MN
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Zip | 55343-9664
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Country | US
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Telephone | 352-529-7314
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 953
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City | COLEMAN
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State | FL
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Zip | 33521-0953
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Country | US
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Telephone | 352-254-0153
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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 | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 7139-33
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | ARNP2975042
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License Number State | FL
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