MEDICARE: ERIN MICHELLE WALLACE M.D.

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	2084P0800X	Psychiatry Physician	MD164348	OR

General Provider Information

NPI Number	:	1730405598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN MICHELLE WALLACE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 3417
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97208-3417
Country	:	US
Telephone Number	:	503-413-3900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1475 MOUNT HOOD AVE STE 160
Second Line	:
City	:	WOODBURN
State	:	OR
Zip	:	97071-9263
Country	:	US
Telephone Number	:	971-983-5214
Fax Number	:

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

Provider Enumeration Date	:	04/19/2010
Last Update Date	:	04/16/2024

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