Individual
JUSTIN DALE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
109 N FAIRLAND ST, PRYOR, OK 74361-4205
(918) 925-1405
Mailing address
109 N FAIRLAND ST, PRYOR, OK 74361-4205
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
175T00000X
OK
Other
Enumeration date
04/21/2022
Last updated
04/21/2022
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