Basic Information
Provider Information | |||||||||
NPI: | 1881697514 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDREW | ||||||||
FirstName: | WALLACE | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3001 EDWARDS MILL RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276125243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197815600 | ||||||||
FaxNumber: | 9197826578 | ||||||||
Practice Location | |||||||||
Address1: | 3001 EDWARDS MILL RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276125243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197815600 | ||||||||
FaxNumber: | 9197826578 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2005 | ||||||||
LastUpdateDate: | 05/04/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 25216 | NC | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 2086S0105X | 25216 | NC | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand |
No ID Information.