Provider Demographics
NPI:1760683924
Name:WALLACE, JAMES G JR (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:G
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1340
Mailing Address - Street 2:STE 100
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-1340
Mailing Address - Country:US
Mailing Address - Phone:509-422-5700
Mailing Address - Fax:
Practice Address - Street 1:525 JAY AVE
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812-3403
Practice Address - Country:US
Practice Address - Phone:509-422-5700
Practice Address - Fax:509-422-7680
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA60167526207Q00000X, 207Q00000X
NC140999390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program