Individual
WILLIAM JACOB WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
105 S WILLOW AVE, COOKEVILLE, TN 38501-4667
(931) 372-7716
(931) 372-0087
Mailing address
203 N CEDAR AVE, COOKEVILLE, TN 38501-2498
(931) 528-1992
(931) 526-4381
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
2743
TN
363AS0400X
Surgical Physician Assistant
Primary
PA2743
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
Q015216
—
TN
Enumeration date
05/16/2015
Last updated
08/27/2020
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