Individual
CAROL ANN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
10180 SE SUNNYSIDE RD, CLACKAMAS, OR 97015-8970
(503) 652-2880
Mailing address
2220 NE 32ND AVE, PORTLAND, OR 97212-5108
(503) 282-6611
Taxonomy
Speciality
Code
Description
License number
State
302R00000X
Health Maintenance Organization
Primary
MD14314
OR
Other
Enumeration date
09/06/2006
Last updated
07/08/2007
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