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General NPI Number Information
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NPI Number | 1780597534
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Entity Type | Individual
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Provider Name | ANTONIO MARQUEZ WALLACE
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Gender | Male
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Dates
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Enumeration Date | 09/23/2026
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Last Update Date | 09/23/2026
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Provider Practice Location Address
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Address Line | 1860 N COOPER ST
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City | ARLINGTON
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State | TX
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Zip | 76011-3639
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Country | US
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Telephone | 817-385-9185
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Fax |
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Provider Business Mailing Address
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Address Line | 2250 SARA JANE PKWY APT 10305
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City | GRAND PRAIRIE
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State | TX
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Zip | 75052-4922
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Country | US
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Telephone | 601-678-1105
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2179103
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License Number State | TX
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