MEDICARE: MAUREEN MARY WALLACE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	3191	AZ

General Provider Information

NPI Number	:	1073559399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAUREEN MARY WALLACE PA-C

Provider Business Mailing Address
First Line	:	2500 E HUNT DR STE H-J
Second Line	:
City	:	SHOW LOW
State	:	AZ
Zip	:	85901-7954
Country	:	US
Telephone Number	:	928-537-6937
Fax Number	:	928-537-3977

Provider Business Practice Location Address
First Line	:	2500 E HUNT DR STE H-J
Second Line	:
City	:	SHOW LOW
State	:	AZ
Zip	:	85901-7954
Country	:	US
Telephone Number	:	928-537-6937
Fax Number	:	928-537-3977

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	06/14/2023

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