1902855612 NPI number — ANNMARIE WALLACE CRNA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902855612 NPI number — ANNMARIE WALLACE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
ANNMARIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MUNTEAN
Provider Other First Name:
ANNMARIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902855612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650426
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75265-0426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-233-1999
Provider Business Mailing Address Fax Number:
972-233-3666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7700 FLOYD CURL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78229-3902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-575-4076
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN-258973 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 733121 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100153 . This is a "EMPLOYER KAISER GROUP #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 120766 . This is a "KAISER PERMANENTE INDV #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 34-0891295 . This is a "EMPLOYER FEDERAL TAX ID #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 7091249 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000220486 . This is a "ANTHEM BCBS INDV #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 89594U . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 730559 . This is a "BUCKEYE COMMUNITY HLTH PL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 182095303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2274926 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2080224 . This is a "UNITED HEALTHCARE GROUP #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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