Basic Information
| Provider Information | |||||||||
| NPI: | 1417344581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | LYDIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 YORK ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036884242 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 HOSPITAL LOOP NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871092129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159286268 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2015 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD2019-0840 | NM | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD2019-08 | 01 | NM | LICENSE | OTHER |