| Doctor Name: | MR. JOHN ROBERT WALLACE |
| NPI Number: | 1275663916 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MSPT |
| License Number: | 5301 |
| Business Practice Address: | 103 W Woodhill Dr Suite A Nags Head, NC - 27959 |
| Business Phone Number: | 2524418580 |
| Business Fax Number: | 2524419551 |
| Mailing Address: | Po Box 716, KILL DEVIL HILLS |
| State: | NC |
| Postal Code: | 27948 |
| Phone Number: | 2524418580 |
| Fax Number: | 2524419551 |
| NPI Enumeration Date: | 03/06/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 5301 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |