=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740371699
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY ANN WALLACE DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 05/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8890 N UNION BLVD STE 170
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80920-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-365-6421
-----------------------------------------------------
Fax | 719-365-6408
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 558 E CASTLE PINES PKWY PMB 151
-----------------------------------------------------
City | CASTLE ROCK
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80108-4608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-365-6421
-----------------------------------------------------
Fax | 710-365-6408
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 27638
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------