Provider Demographics
NPI:1386393551
Name:WALLACE, CHRISTOPHER JACOB (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JACOB
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 SW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-6500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-2100
Practice Address - Country:US
Practice Address - Phone:360-424-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD.MD.61629334207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine