Individual
MR. JERROL B WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
4940 EASTERN AVE, BALTIMORE, MD 21224-2735
(410) 550-0100
Mailing address
6201 GREENLEIGH AVE, MIDDLE RIVER, MD 21220-2004
(410) 933-6423
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
0024167758
VA
367500000X
Certified Registered Nurse Anesthetist
Primary
R246272
MD
Other
Enumeration date
01/31/2007
Last updated
02/16/2021
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