Theodore William Wallace, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA100003556 Issued in WA

Practice address

Madigan Army Medical Ctr
9040A Fitzsimmons Dr
Tacoma, WA 98431-0001

Phone

(253) 968-5161

NPI assigned

Dec 25, 2006

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1167004800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1609931393",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6317 63RD ST W",
            "city": "UNIVERSITY PLACE",
            "state": "WA",
            "postal_code": "984674945"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "MADIGAN ARMY MEDICAL CTR",
            "address_2": "9040A FITZSIMMONS DR",
            "city": "TACOMA",
            "state": "WA",
            "postal_code": "984310001",
            "telephone_number": "253-968-5161"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "THEODORE",
        "middle_name": "WILLIAM",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-12-25",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "WA",
            "license": "PA100003556",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Paul Wayne Wallace, PHARMD
• Renee Elizabeth Wallace
• Shawnly Elise Wallace, PT
• Shelley Renee Wallace, MPH, RD, CN
• Stephanie Ellen Wallace, MD
• Winona Ann Wallace, LMHC
• Tate Wallar
• Jennifer Wallenfels, L.M.P.
• Sheri Lynn Waller, MSW, LCSW, LICSW
• Sydney Lynn Waller, RN

• Physician Assistant in Tacoma, WA
• Providers in Tacoma, WA by specialty
• Physician Assistant in Washington

• 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.

Verify at the official NPI Registry.