Individual
DR. BRIAN KEN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2801 W KINNICKINNIC RIVER PKWY, #250, MILWAUKEE, WI 53215
(414) 649-6732
(414) 649-5840
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(414) 649-6732
(414) 649-5840
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
27108
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
30848800
—
WI
Enumeration date
08/24/2006
Last updated
09/22/2023
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