Most Relevant Information
Provider Data
| NPI Number: | 1003009184 |
| Provider Name: | GARY ROBERT WALLACE PTA |
| Entity Type: | Individual |
| Taxonomy Code: | 225200000X |
| Specialty: | Physical Therapy Assistant |
| License Number: | A2636 |
Most Important Dates
| Enumeration Date: | 08/22/2007 |
| Last Updated: | 08/22/2007 |
Provider Practice Location
13 NORTHTOWN DR
TRINITY REHAB SUITE 110
JACKSON
MS
39211
Practice Location Phone/Fax
| Phone: | 6012069195 |
| Fax: | 6019578391 |
Provider Mailing Location
13 NORTHTOWN DR
SUITE 110 TRINITY REHAB
JACKSON
MS
39211
Provider Mailing Phone/Fax
| Phone: | 6012069195 |
| Fax: | 6019578391 |