Individual
ALLEN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
250 W 300 N, ROOSEVELT, UT 84066-2336
(435) 722-6163
(435) 722-9291
Mailing address
250 W 300 N, ROOSEVELT, UT 84066-2336
(435) 722-6163
(435) 722-9291
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
192839-4406
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
D0808
—
UT
Enumeration date
04/10/2006
Last updated
11/30/2007
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