Individual
CRAIGREON LEVAR WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
6201 HARRY HINES BLVD, DALLAS, TX 75235
(214) 648-3111
Mailing address
PO BOX 845347, DALLAS, TX 75284-7208
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA06903
TX
Other
Enumeration date
12/13/2005
Last updated
08/29/2019
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