Individual
MOIRA PETIRS WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
3625 UNIVERSITY BLVD S, JACKSONVILLE, FL 32216-4207
(904) 702-6111
Mailing address
830-13 A1A NORTH, 232, PONTE VEDRA, FL 32082
(714) 342-3689
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
A120516
CA
207P00000X
Emergency Medicine Physician
Primary
ME133941
FL
Other
Enumeration date
06/26/2009
Last updated
10/26/2023
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