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Individual

JOHN WALLACE SR.

Active
Sole proprietor

Provider details

NPI number
Gender
Man
Credential
IDC

Contact information

Practice address
300 E MAIN ST, SUITE 1000, NORFOLK, VA 23510-1753
(757) 628-4347
Mailing address
235 JONATHANS WAY, SUFFOLK, VA 23434-9153
(757) 923-3793

Taxonomy

Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary

Other

Enumeration date
01/11/2006
Last updated
07/08/2007
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