Provider Demographics
NPI:1306948948
Name:WALLACE, ROBIN PATRICIA (DOM, LIC AC)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:PATRICIA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DOM, LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 422
Mailing Address - Street 2:
Mailing Address - City:GLORIETA
Mailing Address - State:NM
Mailing Address - Zip Code:87535
Mailing Address - Country:US
Mailing Address - Phone:505-231-6684
Mailing Address - Fax:505-884-4015
Practice Address - Street 1:146 GLORY LANE
Practice Address - Street 2:
Practice Address - City:GLORIETA
Practice Address - State:NM
Practice Address - Zip Code:87535
Practice Address - Country:US
Practice Address - Phone:505-231-6684
Practice Address - Fax:505-884-4015
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK000355L171100000X
PAKO000048L171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1824619OtherHIGHMARK BS-PREM