Provider Demographics
NPI:1992936066
Name:WALLACE, BENJAMIN P (PA)
Entity type:Individual
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First Name:BENJAMIN
Middle Name:P
Last Name:WALLACE
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Gender:M
Credentials:PA
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Mailing Address - Street 1:3600 NW SAMARITAN DRIVE
Mailing Address - Street 2:SUITE 227
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3737
Mailing Address - Country:US
Mailing Address - Phone:541-768-5223
Mailing Address - Fax:541-768-5014
Practice Address - Street 1:3600 NW SAMARITAN DRIVE
Practice Address - Street 2:SUITE 227
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3737
Practice Address - Country:US
Practice Address - Phone:541-768-5223
Practice Address - Fax:541-768-5014
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical