Individual
RICHARD ANTHONY WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
8045 ROANE MEDICAL CENTER DR, HARRIMAN, TN 37748-8333
(865) 316-1000
Mailing address
969 OAK RIDGE TPKE # 316, OAK RIDGE, TN 37830-8832
(865) 256-7711
(866) 548-0571
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
9332
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0454102553
TRICARE SOUTH HUMANA MILITARY
TN
01
—
1527480
TENNCARE, EFFECTIVE 4/5/12
TN
05
—
1527480
—
TN
01
—
171975592453
HUMANA
TN
01
—
3037582
CIGNA
TN
01
—
4317478
BCBS - COVER TENNESSEE
TN
01
—
454102553
HUMANA GOLD
TN
01
—
616644300
DEPT OF LABOR WORKER'S COMP - DEEOIC PROGRAM
TN
Enumeration date
04/08/2006
Last updated
09/25/2013
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