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General NPI Number Information
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NPI Number | 1396087623
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Entity Type | Individual
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Provider Name | CARL BRADLEY WALLIS MD
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Gender | Male
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Dates
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Enumeration Date | 03/25/2013
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Last Update Date | 06/27/2019
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Provider Practice Location Address
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Address Line | 10561 JEFFREYS ST STE 230
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City | HENDERSON
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State | NV
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Zip | 89052-4268
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Country | US
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Telephone | 702-565-6565
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Fax | 702-565-8898
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Provider Business Mailing Address
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Address Line | 10561 JEFFREYS ST STE 230
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City | HENDERSON
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State | NV
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Zip | 89052-4268
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Country | US
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Telephone | 702-565-6565
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Fax | 702-565-8898
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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 | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 18947
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License Number State | NV
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