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NPI Code Detail

MEDICARE: MICHAEL JON WALLACE CPSW

MEDICARE: MICHAEL JON WALLACE CPSW
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
1175T00000XPeer SpecialistNM

General Provider Information

NPI Number : 1659238392
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHAEL JON WALLACE CPSW
Provider Business Mailing Address
First Line : 385 CALLE DE ALEGRA BLDG A
Second Line :
City : LAS CRUCES
State : NM
Zip : 88005-3423
Country : US
Telephone Number : 575-526-1105
Fax Number : 575-524-4266
Provider Business Practice Location Address
First Line : 760 N MOTEL BLVD
Second Line :
City : LAS CRUCES
State : NM
Zip : 88007-4169
Country : US
Telephone Number : 575-527-7975
Fax Number : 575-674-2861
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/06/2026
Last Update Date : 01/06/2026

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Directions to “ MICHAEL JON WALLACE CPSW” Practice Location

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