Robert Jason Wallace, ATC

Primary specialty

Athletic TrainerTaxonomy code 2255A2300X

License

2601001545 Issued in MI

Practice address

261 Mack Ave
Detroit, MI 48201-2417

Phone

(313) 966-7246

NPI assigned

Oct 24, 2024

Sex

Male

Sole proprietor

No

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": "1729728000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1729728000000",
    "number": "1972325603",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8946 SAN MARCO BLVD",
            "city": "STERLING HEIGHTS",
            "state": "MI",
            "postal_code": "483134866",
            "telephone_number": "586-488-6467"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "261 MACK AVE",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482012417",
            "telephone_number": "313-966-7246"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "ROBERT",
        "middle_name": "JASON",
        "name_prefix": "Mr.",
        "credential": "ATC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2024-10-24",
        "last_updated": "2024-10-24",
        "certification_date": "2024-10-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "MI",
            "license": "2601001545",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kacie Wallace, M.S., PA-C
• Kelsey Wallace, LMT
• Margaret L Wallace, PA
• Mercedes Wallace
• Priscilla Wallace
• Tiffany Astra Wallace, LLBSW
• Tracy Wallace
• Cynthia Waller
• Jamie Waller
• Latonya Waller, DDS

• Athletic Trainer in Detroit, MI
• Providers in Detroit, MI by specialty
• Athletic Trainer in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 24, 2024; 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.