Individual
MADELINE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
2930 11TH AVE, EVANS, CO 80620-1011
(970) 353-9403
Mailing address
2930 11TH AVE, EVANS, CO 80620-1011
(970) 353-9403
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
6761
CO
Other
Enumeration date
05/07/2021
Last updated
06/29/2021
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