MEDICARE: SHARON WALLACE

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	225100000X	Physical Therapist		TX

General Provider Information

NPI Number	:	1831085745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHARON WALLACE

Provider Business Mailing Address
First Line	:	109 W HOYT DR
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75601-3614
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 W HOYT DR
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75601-3614
Country	:	US
Telephone Number	:	430-201-5645
Fax Number	:	903-207-5406

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

Provider Enumeration Date	:	06/16/2025
Last Update Date	:	06/16/2025

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Directions to “ SHARON WALLACE ” Practice Location

Language	Start Address	Practice Location

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