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Individual
ROBERT WALLACE
Active
Individual
ROBERT WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA, NP
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
PA20650
CA
363LF0000X
Family Nurse Practitioner
Primary
19738
CA
Other
Enumeration date
11/03/2009
Last updated
06/11/2012
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