Individual
MR. WALLACE MAXWELL GREEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
1275 HIGHWAY 54 W, STE.105, FAYETTEVILLE, GA 30214-4549
(770) 719-2965
(770) 719-2963
Mailing address
1275 HIGHWAY 54 W, STE.105, FAYETTEVILLE, GA 30214-4549
(770) 719-2965
(770) 719-2963
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
001827
GA
Other
Enumeration date
03/13/2007
Last updated
07/08/2007
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