Individual
MATTHEW FRENCH WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1100 3RD ST, TILLAMOOK, OR 97141-3402
(503) 842-5546
Mailing address
1100 3RD ST, TILLAMOOK, OR 97141-3402
(503) 842-5546
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
60923310
WA
363A00000X
Physician Assistant
Primary
PA184421
OR
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
60923310
WA STATE LICENSE
WA
01
—
PA184421
OR STATE LICENSE
OR
Enumeration date
05/23/2016
Last updated
07/27/2021
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