Most Relevant Information
Provider Data
| NPI Number: | 1003057852 |
| Provider Name: | MICHAEL ALAN WALLACE CNP |
| Entity Type: | Individual |
| Taxonomy Code: | 363LF0000X |
| Specialty: | Nurse Practitioner |
| License Number: | R48828 |
Most Important Dates
| Enumeration Date: | 03/07/2009 |
| Last Updated: | 03/11/2013 |
Provider Practice Location
8210 LOUISIANA BLVD NE
SUITE C
ALBUQUERQUE
NM
871131761
Practice Location Phone/Fax
| Phone: | 5058581222 |
| Fax: | 5058581224 |
Provider Mailing Location
8210 LOUISIANA BLVD NE
SUITE C
ALBUQUERQUE
NM
871131761
Provider Mailing Phone/Fax
| Phone: | 5058581222 |
| Fax: | 5058581224 |