Individual
MARTY DALE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
1114 SUNSET DR, SUITE 4, JOHNSON CITY, TN 37604-2969
(423) 283-0776
(423) 283-0549
Mailing address
PO BOX 3727, JOHNSON CITY, TN 37602-3727
(423) 283-0776
(423) 283-0549
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
APN13700
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1510077
—
TN
Enumeration date
10/15/2008
Last updated
11/20/2009
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