Provider Demographics
NPI:1396736997
Name:WALLACE, TASHA B (DO)
Entity type:Individual
Prefix:DR
First Name:TASHA
Middle Name:B
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:14651 PALM BEACH BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-2331
Mailing Address - Country:US
Mailing Address - Phone:239-369-2903
Mailing Address - Fax:239-369-0500
Practice Address - Street 1:14651 PALM BEACH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-2331
Practice Address - Country:US
Practice Address - Phone:239-369-2903
Practice Address - Fax:239-369-0500
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2024-08-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS8622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH90975Medicare UPIN
FLU1026YMedicare PIN