Individual
MICHAEL T WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ARNP
Contact information
Practice address
9900 BREN RD E, MINNETONKA, MN 55343-9664
(352) 529-7314
Mailing address
PO BOX 953, COLEMAN, FL 33521-0953
(352) 254-0153
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
7139-33
WI
363LA2200X
Adult Health Nurse Practitioner
Primary
ARNP2975042
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
007980600
—
FL
Enumeration date
12/22/2010
Last updated
03/07/2023
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