Individual
JASON R. WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
12554 RIATA VISTA CIRCLE, AUSTIN, TX 78727-6432
(512) 795-5100
(512) 795-5122
Mailing address
12554 RIATA VISTA CIRCLE, AUSTIN, TX 78727-6432
(512) 795-5100
(512) 795-5122
Taxonomy
Speciality
Code
Description
License number
State
2085B0100X
Body Imaging Physician
MD00046651
WA
2085R0202X
Diagnostic Radiology Physician
Primary
M9727
TX
Other
Enumeration date
08/31/2006
Last updated
02/01/2018
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