| Doctor Name: | MR. MICHAEL ALAN WALLACE |
| NPI Number: | 1003057852 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | CNP |
| License Number: | R48828 |
| Business Practice Address: | 8210 Louisiana Blvd Ne Suite C Albuquerque, NM - 871131761 |
| Business Phone Number: | 5058581222 |
| Business Fax Number: | 5058581224 |
| Mailing Address: | 8210 Louisiana Blvd Ne, Suite C ALBUQUERQUE |
| State: | NM |
| Postal Code: | 871131761 |
| Phone Number: | 5058581222 |
| Fax Number: | 5058581224 |
| NPI Enumeration Date: | 03/07/2009 |
| NPI Last Update Date: | 03/11/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | R48828 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NM |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |