Basic Information
| Provider Information | |||||||||
| NPI: | 1467429860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 W CENTRAL AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163229813 | ||||||||
| FaxNumber: | 3163229806 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W CENTRAL AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163229813 | ||||||||
| FaxNumber: | 3163229806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
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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 | 363LF0000X | KS44943 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | KS | MEDICAID |