Individual
JONATHAN WESLEY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
100 E 33RD ST STE 100, VANCOUVER, WA 98663-2776
(360) 514-7556
Mailing address
100 E 33RD ST STE 100, VANCOUVER, WA 98663-2776
(360) 514-7556
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
ML61440736
WA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
05/01/2023
Last updated
05/05/2023
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