Individual
MR. TREVOR J WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
988 OAK RIDGE TPKE STE 100, OAK RIDGE, TN 37830-6919
(865) 690-4861
(865) 483-4194
Mailing address
PO BOX 306556, NASHVILLE, TN 37230-6556
(865) 694-0062
(865) 694-7907
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
6270
TN
363A00000X
Physician Assistant
8236
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003185899A
—
GA
05
—
003185899B
—
GA
05
—
003185899C
—
GA
Enumeration date
01/17/2017
Last updated
11/19/2024
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