Basic Information
| Provider Information | |||||||||
| NPI: | 1356329114 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 W 5TH AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093442663 | ||||||||
| FaxNumber: | 5096249179 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 E CENTRAL AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992086289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094651300 | ||||||||
| FaxNumber: | 5094651313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 11/15/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 47815 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | MD60144423 | WA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 265453900 | 05 | MN | MEDICAID | 2007981 | 05 | WA | MEDICAID |