Individual
MR. MATTHEW EDWIN WALLACE
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
ATC, PES
Contact information
Practice address
CREIGHTON UNIUVERSITY, 2500 CALIFORNIA PLAZA, OMAHA, NE 68178-0001
(402) 280-5563
(402) 280-3110
Mailing address
2932 S 93RD PLZ, APT. 5, OMAHA, NE 68124-2823
(402) 990-4004
(402) 280-3110
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
378
NE
Other
Enumeration date
06/15/2006
Last updated
07/08/2007
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