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NPI Code Detail

MEDICARE: PHILLIP TYLER WALLACE APRN

MEDICARE: PHILLIP TYLER WALLACE APRN
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
1363L00000XNurse PractitionerAPRN11003275FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1821647447
Entity Type Code : Individual
Provider Name (Legal Business Name) : PHILLIP TYLER WALLACE APRN
Provider Business Mailing Address
First Line : 1325 SAN MARCO BLVD STE 300
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32207-8567
Country : US
Telephone Number : 904-253-6910
Fax Number : 904-253-6964
Provider Business Practice Location Address
First Line : 1325 SAN MARCO BLVD STE 300
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32207-8567
Country : US
Telephone Number : 904-253-6910
Fax Number : 904-253-6964
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/06/2019
Last Update Date : 03/24/2026

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Directions to “ PHILLIP TYLER WALLACE APRN” Practice Location

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