| Doctor Name: | DR. MAEGEN J WALLACE |
| NPI Number: | 1235393836 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | M.D. |
| License Number: | 2008018502 |
| Business Practice Address: | Emile 42nd St Omaha, NE - 681980001 |
| Business Phone Number: | 4029558125 |
| Business Fax Number: | 4029558140 |
| Mailing Address: | Emile 42nd St, OMAHA |
| State: | NE |
| Postal Code: | 681980001 |
| Phone Number: | 4029558125 |
| Fax Number: | 4029558140 |
| NPI Enumeration Date: | 07/12/2008 |
| NPI Last Update Date: | 07/10/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | 2008018502 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MO |
| 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. |