Khalil Rashaun Wallace

Primary specialty

Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X

Practice address

7275 Nebraska Ave
Fairchild AFB, WA 99011-3001

Phone

(786) 512-1492

NPI assigned

Sep 19, 2016

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

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

{
    "created_epoch": "1474243200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1474243200000",
    "number": "1528516580",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7275 NEBRASKA AVE",
            "city": "FAIRCHILD AFB",
            "state": "WA",
            "postal_code": "990113001"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7275 NEBRASKA AVE",
            "city": "FAIRCHILD AFB",
            "state": "WA",
            "postal_code": "990113001",
            "telephone_number": "786-512-1492"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KHALIL",
        "middle_name": "RASHAUN",
        "name_prefix": "Mr.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2016-09-19",
        "last_updated": "2016-09-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sunland Optical Co., Inc.
• Pamela Jan Tilaro, N.P.
• Alicia Louise Tschirhart, M.D.
• John Edward Vickman, M.D
• Marc Palmones Villano, IDMT
• Todd Samuel Weller, D.M.D.
• Ryan Werner, IDMT
• Matthew Robert Wilcox, IDMT
• Jeff K Williams, LCSW
• Tiffany Williams, DNP

• Student in an Organized Health Care Education/Training Program in Fairchild AFB, WA
• Providers in Fairchild AFB, WA by specialty
• Student in an Organized Health Care Education/Training Program in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 19, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.