Individual
BRYAN MICHAEL WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
SOIDC
Contact information
Practice address
1ST MARINE RAIDER BATTALION, STONE BAY, CAMP LEJEUNE, NC 28542
(910) 440-2504
Mailing address
PSC BOX 20184, CAMP LEJEUNE, NC 28542
(910) 440-2504
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
—
—
Other
Enumeration date
06/27/2023
Last updated
06/30/2023
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