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Individual
THOMAS EVANS WALLACE
Active
Individual
THOMAS EVANS WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD045078L
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
001280114
—
PA
01
—
707439F6K
MEDICARE
PA
Enumeration date
06/22/2006
Last updated
10/05/2022
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