Active NPI
John G Wallace, M.D.
- Psychiatry Physician
- Shoreline, WA
National Provider Identifier
1346379161
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- 00008964
- Practice address
- 17515 N Park PL N
Shoreline, WA 98133-4803 - Phone
- (206) 533-2158
- Fax
- (206) 533-2158
- NPI assigned
- Mar 5, 2007
- Sex
- Male
- Sole proprietor
- Yes
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 |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | 00008964 | WA | Primary |
Addresses
Primary practice location
17515 N Park PL N
Shoreline, WA 98133-4803
Mailing address
17515 N Park PL N
Shoreline, WA 98133-4803
Phone (206) 533-2158
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)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 00008964 | WA | MD | Psychiatry Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1173052800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1346379161",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "17515 N PARK PL N",
"city": "SHORELINE",
"state": "WA",
"postal_code": "981334803",
"telephone_number": "206-533-2158",
"fax_number": "206-533-2158"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "17515 N PARK PL N",
"city": "SHORELINE",
"state": "WA",
"postal_code": "981334803",
"telephone_number": "206-533-2158",
"fax_number": "206-533-2158"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "JOHN",
"middle_name": "G",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-03-05",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "WA",
"license": "00008964",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Shoreline, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.