Provider Demographics
NPI:1194171579
Name:WALLACE, MEGHAN ELIZABETH
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:ELIZABETH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:ELIZABETH
Other - Last Name:WILLCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:730 SE OAK ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4245
Mailing Address - Country:US
Mailing Address - Phone:503-640-3724
Mailing Address - Fax:
Practice Address - Street 1:730 SE OAK ST
Practice Address - Street 2:SUITE D
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4245
Practice Address - Country:US
Practice Address - Phone:503-640-3724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201507676N363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily