Individual
MR. TERRELL RICHARD WALLACE JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA C
Contact information
Practice address
136 SOUTH HOUSTON LAKE ROAD, WARNER ROBINS, GA 31088
(478) 953-1020
(478) 953-5406
Mailing address
207 ESPLANADE DRIVE, WARNER ROBINS, GA 31088
(478) 922-3061
(478) 953-5406
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
002665
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DC3326
MCR RR
—
01
—
P00162033
MCR RR
—
Enumeration date
05/05/2006
Last updated
09/18/2012
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