Basic Information
| Provider Information | |||||||||
| NPI: | 1003296484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | HUGH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 319 SPRINGWOOD DR NE | ||||||||
| Address2: | |||||||||
| City: | VALDESE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286908710 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 319 SPRINGWOOD DR NE | ||||||||
| Address2: | |||||||||
| City: | VALDESE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286908710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288798419 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2015 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 246400 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.