Individual
BLAKE TAYLOR WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
15601 N 28TH AVE STE 102, PHOENIX, AZ 85053-4061
(480) 844-8218
Mailing address
PO BOX 32611, BELFAST, ME 04915-0219
(480) 844-8218
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
POD-001117
AZ
Other
Enumeration date
11/14/2020
Last updated
07/29/2024
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