Provider Demographics
NPI:1962781880
Name:WALLACE, TAMARA (PTA)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 4TH ST
Mailing Address - Street 2:APT 826
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-1604
Mailing Address - Country:US
Mailing Address - Phone:916-205-1299
Mailing Address - Fax:
Practice Address - Street 1:333 GELLERT BLVD
Practice Address - Street 2:#150
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2621
Practice Address - Country:US
Practice Address - Phone:650-758-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6816225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant