Active NPI
Michael Alan Wallace, CNP
- Family Nurse Practitioner
- Albuquerque, NM
National Provider Identifier
1003057852
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Nurse Practitioner
- License
- R48828
- Practice address
- 8210 Louisiana Blvd NE
Suite C
Albuquerque, NM 87113-1761 - Phone
- (505) 858-1222
- Fax
- (505) 858-1224
- NPI assigned
- Mar 7, 2009
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | R48828 | NM | Primary |
Addresses
Primary practice location
8210 Louisiana Blvd NE
Suite C
Albuquerque, NM 87113-1761
Mailing address
8210 Louisiana Blvd NE
Suite C
Albuquerque, NM 87113-1761
Phone (505) 858-1222
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 29623341 | Medicaid | NM |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Certified Nurse Practitioner, Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| R48828 | NM | MD | Family Nurse Practitioner |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1236384000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1362960000000",
"number": "1003057852",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "8210 LOUISIANA BLVD NE",
"address_2": "SUITE C",
"city": "ALBUQUERQUE",
"state": "NM",
"postal_code": "871131761",
"telephone_number": "505-858-1222",
"fax_number": "505-858-1224"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "8210 LOUISIANA BLVD NE",
"address_2": "SUITE C",
"city": "ALBUQUERQUE",
"state": "NM",
"postal_code": "871131761",
"telephone_number": "505-858-1222",
"fax_number": "505-858-1224"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "MICHAEL",
"middle_name": "ALAN",
"name_prefix": "Mr.",
"credential": "CNP",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2009-03-07",
"last_updated": "2013-03-11",
"status": "A"
},
"taxonomies": [
{
"code": "363LF0000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Family",
"state": "NM",
"license": "R48828",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "29623341",
"state": "NM"
}
],
"endpoints": [],
"other_names": []
}Other providers in Albuquerque, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 11, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.