Individual
MR. THEODORE WILLIAM WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
MADIGAN ARMY MEDICAL CTR, 9040A FITZSIMMONS DR, TACOMA, WA 98431-0001
(253) 968-5161
Mailing address
6317 63RD ST W, UNIVERSITY PLACE, WA 98467-4945
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA100003556
WA
Other
Enumeration date
12/25/2006
Last updated
07/08/2007
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