Basic Information
Provider Information | |||||||||
NPI: | 1851379119 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALLACE | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 505 S 336TH ST | ||||||||
Address2: | SUITE 600 | ||||||||
City: | FEDERAL WAY | ||||||||
State: | WA | ||||||||
PostalCode: | 980036328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538386180 | ||||||||
FaxNumber: | 2538386418 | ||||||||
Practice Location | |||||||||
Address1: | 1200 COLLEGE DR | ||||||||
Address2: |   | ||||||||
City: | ROCK SPRINGS | ||||||||
State: | WY | ||||||||
PostalCode: | 829015868 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3073623711 | ||||||||
FaxNumber: | 3073528178 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2006 | ||||||||
LastUpdateDate: | 05/06/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | M8716 | ID | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 6690A | WY | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 605960009 | 01 | WY | FBL | OTHER | 314686 | 01 | WY | BSWY | OTHER | 806470900 | 05 | ID |   | MEDICAID | 58024 | 01 | ID | BLUE CROSS OF ID | OTHER |