Basic Information
Provider Information | |||||||||
NPI: | 1235393836 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALLACE | ||||||||
FirstName: | MAEGEN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | EMILE 42ND ST | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681980001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4029558125 | ||||||||
FaxNumber: | 4029558140 | ||||||||
Practice Location | |||||||||
Address1: | EMILE 42ND ST | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681980001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4029558125 | ||||||||
FaxNumber: | 4029558140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2008 | ||||||||
LastUpdateDate: | 07/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 2008018502 | MO | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207XP3100X | 28403 | NE | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
No ID Information.