Individual
DR. BRENT E WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1915 W 5950 S, ROY, UT 84067-1454
(801) 387-8100
Mailing address
PO BOX 27128, SALT LAKE CITY, UT 84127-0128
(801) 387-8100
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
771610101205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
870348215008
—
UT
Enumeration date
08/28/2006
Last updated
07/10/2008
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