Individual
SAMANTHA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
3801 S NATIONAL AVE, SPRINGFIELD, MO 65807-5210
(417) 269-7728
(417) 269-7729
Mailing address
PO BOX 802843, KANSAS CITY, MO 64180-2843
(417) 269-5712
(417) 269-7567
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
2014019168
MO
207Q00000X
Family Medicine Physician
Primary
2015026152
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1821403593
—
MO
Enumeration date
06/21/2014
Last updated
11/10/2020
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