Basic Information
| Provider Information | |||||||||
| NPI: | 1255510848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | DARLENE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 806 TANGLE WAY CT | ||||||||
| Address2: | |||||||||
| City: | CEDAR HILL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751047818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122160743 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 HILLCREST MEDICAL BLVD | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767128897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542025631 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | M7736 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.