MEDICARE: DR. SHAUNE WALLACE OD

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	152W00000X	Optometrist	931	NV

General Provider Information

NPI Number	:	1467550335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAUNE WALLACE OD

Provider Business Mailing Address
First Line	:	1657 MOUNTAIN CITY HWY STE 101
Second Line	:
City	:	ELKO
State	:	NV
Zip	:	89801-2809
Country	:	US
Telephone Number	:	775-738-6727
Fax Number	:

Provider Business Practice Location Address
First Line	:	1657 MOUNTAIN CITY HWY STE 101
Second Line	:
City	:	ELKO
State	:	NV
Zip	:	89801-2809
Country	:	US
Telephone Number	:	775-738-6727
Fax Number	:

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	06/06/2023

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