| Doctor Name: | WALLACE LYLE PAST |
| NPI Number: | 1871868802 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | 01018231A |
| Business Practice Address: | 4608 Heritage Manor Crestwood, KY - 40014 |
| Business Phone Number: | 5026146688 |
| Business Fax Number: | 5026146688 |
| Mailing Address: | 4608 Heritage Manor, CRESTWOOD |
| State: | KY |
| Postal Code: | 40014 |
| Phone Number: | 5026146688 |
| Fax Number: | 5026146688 |
| NPI Enumeration Date: | 03/08/2012 |
| NPI Last Update Date: | 03/08/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 01018231A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |