1902855612 NPI number — ANNMARIE WALLACE CRNA

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

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 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:

1902855612

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/07/2013

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

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 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

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• 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" .

• 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".