Basic Information
| Provider Information | |||||||||
| NPI: | 1891793923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5255 EL CAMINO REAL STE C | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934223351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052370272 | ||||||||
| FaxNumber: | 8052372416 | ||||||||
| Practice Location | |||||||||
| Address1: | 5255 EL CAMINO REAL STE C | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934223351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052370272 | ||||||||
| FaxNumber: | 8052372416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10294 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.