Basic Information
Provider Information
NPI: 1003296484
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WALLACE
FirstName: JOHN
MiddleName: HUGH
NamePrefix: MR.
NameSuffix: JR.
Credential: FNP-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 319 SPRINGWOOD DR NE
Address2:  
City: VALDESE
State: NC
PostalCode: 286908710
CountryCode: US
TelephoneNumber:  
FaxNumber:  
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: 06/01/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X246400NCY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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