Individual
SHARON K WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
70 DOCTORS' PARK, CAPE GIRARDEAU, MO 63703
(573) 334-6071
(573) 334-4739
Mailing address
70 DOCTORS' PARK, CAPE GIRARDEAU, MO 63703
(573) 334-6071
(573) 334-4739
Taxonomy
Speciality
Code
Description
License number
State
2085N0700X
Neuroradiology Physician
2009008972
MO
2085R0202X
Diagnostic Radiology Physician
Primary
2009008972
MO
2085R0202X
Diagnostic Radiology Physician
D0063205
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
408165000
—
MD
01
—
KDA7 / 645989-01
BC / BS OF MD
MD
01
—
S187 / 0024
BLUECHOICE
MD
Enumeration date
05/23/2006
Last updated
12/04/2013
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