Provider Demographics
NPI:1912361502
Name:WALLACE, ANDREW NELS (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:NELS
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9201 E MOUNTAIN VIEW RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5140
Mailing Address - Country:US
Mailing Address - Phone:480-587-6970
Mailing Address - Fax:
Practice Address - Street 1:9201 E MOUNTAIN VIEW RD STE 105
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5140
Practice Address - Country:US
Practice Address - Phone:480-587-6970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ011500207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine