Basic Information
| Provider Information | |||||||||
| NPI: | 1639175292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 RAVEN HILL DRIVE | ||||||||
| Address2: | |||||||||
| City: | ATCHISON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660021243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133677300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 810 RAVEN HILL DRIVE | ||||||||
| Address2: | |||||||||
| City: | ATCHISON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660021401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133676689 | ||||||||
| FaxNumber: | 9133605837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 01/28/2010 | ||||||||
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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 | 207Q00000X | 0413701 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100098780I | 05 | KS | MEDICAID |