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General NPI Number Information
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NPI Number | 1972556447
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Entity Type | Individual
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Provider Name | WALLACE EUGENE RALSTON CRNA
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Gender | Male
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Dates
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Enumeration Date | 05/18/2006
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Last Update Date | 04/03/2025
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Provider Practice Location Address
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Address Line | 2305 S 65 HIGHWAY
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City | MARSHALL
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State | MO
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Zip | 65340
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Country | US
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Telephone | 660-886-3554
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Fax | 660-831-3308
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Provider Business Mailing Address
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Address Line | 2305 SOUTH 65 HIGHWAY
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City | MARSHALL
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State | MO
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Zip | 65340-2640
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Country | US
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Telephone | 660-886-7431
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 2020034592
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 152532
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License Number State | MO
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