Individual
MR. WALLACE PAUL ODOM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
911 BIG COVE RD SE, HUNTSVILLE, AL 35801-3750
(256) 265-8120
(256) 265-8969
Mailing address
PO BOX 1389, HUNTSVILLE, AL 35807-0389
(205) 979-5882
(205) 979-1248
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
1-071049
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
051526353
—
AL
01
—
51526353
BCBS #
AL
01
—
P00216451
RR MEDICARE #
AL
Enumeration date
02/16/2006
Last updated
12/04/2008
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