Individual
JESSE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1138 WATERFALL LN, LENOIR, NC 28645-8943
(702) 102-7922
Mailing address
1138 WATERFALL LN, LENOIR, NC 28645-8943
(702) 102-7922
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
19466
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
64194665
—
KY
Enumeration date
11/07/2006
Last updated
06/06/2019
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