NPIMap

Individual provider Active NPI

Brian Wallace, N.P.

  • Primary Care Nurse Practitioner
  • Tyler, TX
National Provider Identifier
1457561615
Registry record updated Mar 12, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Nurse PractitionerTaxonomy code 363LP2300X
License
RN 169685C Issued in CO
Practice address
1910 Roseland Blvd
Tyler, TX 75701-4246
Phone
(903) 533-0644
NPI assigned
May 23, 2007
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 12, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Nurse Practitioner 363LP2300X RN 169685C CO Primary

Addresses

Primary practice location

1910 Roseland Blvd
Tyler, TX 75701-4246

Mailing address

1910 Roseland Blvd
Tyler, TX 75701-4246
Phone (903) 533-0644

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20220714000066 CO Practitioner - Nurse Practitioner 6103913389 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2007
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

Broomfield, CO 80021
Phone (720) 807-4461

21750 E Quincy Ave
Copperleaf Clinic Primary Care
Aurora, CO 80015-2894
Phone (303) 812-6880

8350 Colorado Blvd
Unit 160
Firestone, CO 80504-6803
Phone (303) 673-1370

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
RN 169685CCOMDPrimary Care Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Intermountain Medical Group Denver, LLC CurrentSince May 31, 2022 Accepting new patients
Intermountain Medical Group Denver, LLC CurrentSince May 31, 2022 Accepting new patients
Intermountain Medical Group Denver, LLC Current Accepting new patients
Atul Shetty, MD LLC Past Accepting new patients

Locations

21750 E Quincy Ave
Aurora, CO 80015
Phone (303) 812-5173

500 Eldorado Blvd
Ste 4300
Broomfield, CO 80021

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 21

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179878400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1268352000000",
    "number": "1457561615",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1910 ROSELAND BLVD",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757014246",
            "telephone_number": "903-533-0644",
            "fax_number": "903-533-0441"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1910 ROSELAND BLVD",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757014246",
            "telephone_number": "903-533-0644"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "BRIAN",
        "credential": "N.P.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-05-23",
        "last_updated": "2010-03-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "CO",
            "license": "RN 169685C",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tyler, TX

Sources for this page

Verify at the official NPI Registry.