Individual
MR. MICHAEL ALAN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CNP
Contact information
Practice address
8210 LOUISIANA BLVD NE, SUITE C, ALBUQUERQUE, NM 87113-1761
(505) 858-1222
(505) 858-1224
Mailing address
8210 LOUISIANA BLVD NE, SUITE C, ALBUQUERQUE, NM 87113-1761
(505) 858-1222
(505) 858-1224
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
R48828
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
29623341
—
NM
Enumeration date
03/07/2009
Last updated
03/11/2013
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