Provider Demographics
NPI:1306979059
Name:GREEN, WALLACE MAXWELL (PAC)
Entity type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:MAXWELL
Last Name:GREEN
Suffix:
Gender:M
Credentials:PAC
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Mailing Address - Street 1:1275 HIGHWAY 54 W
Mailing Address - Street 2:STE.105
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4549
Mailing Address - Country:US
Mailing Address - Phone:770-719-2965
Mailing Address - Fax:770-719-2963
Practice Address - Street 1:1275 HIGHWAY 54 W
Practice Address - Street 2:STE.105
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4549
Practice Address - Country:US
Practice Address - Phone:770-719-2965
Practice Address - Fax:770-719-2963
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0018272084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology