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General NPI Number Information
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NPI Number | 1396281200
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Entity Type | Individual
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Provider Name | TREVOR J WALLACE PA-C
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Gender | Male
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Dates
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Enumeration Date | 01/17/2017
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Last Update Date | 11/19/2024
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Provider Practice Location Address
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Address Line | 988 OAK RIDGE TPKE STE 100
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City | OAK RIDGE
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State | TN
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Zip | 37830-6919
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Country | US
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Telephone | 865-690-4861
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Fax | 865-483-4194
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Provider Business Mailing Address
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Address Line | PO BOX 306556
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City | NASHVILLE
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State | TN
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Zip | 37230-6556
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Country | US
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Telephone | 865-694-0062
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Fax | 865-694-7907
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 8236
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 6270
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License Number State | TN
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