| Doctor Name: | IAN WALLACE |
| NPI Number: | 1063732758 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | |
| Business Practice Address: | 220 E Rogers Rd Longmont, CO - 805016027 |
| Business Phone Number: | 3037763250 |
| Business Fax Number: | 3036829269 |
| Mailing Address: | 203 S Rollie Ave, FORT LUPTON |
| State: | CO |
| Postal Code: | 806211508 |
| Phone Number: | 3032864560 |
| Fax Number: | 3032864589 |
| NPI Enumeration Date: | 06/04/2010 |
| NPI Last Update Date: | 11/14/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |