Individual
HAILY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
402 E MIEL DE LUNA AVE, PMG AT DR DAN C TRIGG MEMORIAL HOSPITAL, TUCUMCARI, NM 88401-3828
(575) 461-7100
(575) 461-7101
Mailing address
PO BOX 26666, PHS PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD2014-0895
NM
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/05/2012
Last updated
06/18/2015
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