Individual
MIATA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
1500 S 58TH ST STE 800, LINCOLN, NE 68506-1407
(402) 483-8600
(402) 483-8689
Mailing address
1500 S 58TH ST STE 800, LINCOLN, NE 68506-1407
(402) 483-8600
(402) 483-8689
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2760
NE
Other
Enumeration date
05/31/2022
Last updated
03/25/2025
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