Individual
LANCE T WALLACE
Active
Individual
LANCE T WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
01095489A
IN
207R00000X
Internal Medicine Physician
036085478
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036085478
—
IL
01
—
IL5686032
MEDICARE PTAN
IL
Enumeration date
06/08/2006
Last updated
07/15/2026
Update your record
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