Individual
KENT WILLIAM WALLACE
Active
Individual
KENT WILLIAM WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C, ARNP
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
PA10000442
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
124775
LABOR AND INDUSTRIES
WA
01
—
8803430
RAILROAD MEDICARE
WA
01
—
WA6512
REGENCE
WA
Enumeration date
11/02/2006
Last updated
02/06/2015
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