Individual
KRISTINA MARIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
537 UNION AVE, SECOND FLOOR, GRANTS PASS, OR 97527-5543
(541) 479-6777
Mailing address
1115 SE 164TH AVE DEPT 358, VANCOUVER, WA 98683-8004
(360) 729-1253
(360) 729-3185
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA174747
OR
Other
Enumeration date
09/15/2015
Last updated
06/08/2020
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