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1124614706
SHAWN MICHAEL WALLACE
RIO RANCHO, NM
NPI
1124614706
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Entity Type
Individual
Gender
Male
Sole Proprietor ?
No
Primary Taxonomy
363A00000X Physician Assistant
(Licence: NM PA2022-0064)
Enumeration Date
2020-12-17
Last Update Date
2022-10-28
Business Address
Mr. SHAWN MICHAEL WALLACE PA-C
2400 UNSER BLVD SE STE 08100
RIO RANCHO, NM 87124
Phone number: 505-253-6100
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Mailing Address
Mr. SHAWN MICHAEL WALLACE PA-C
PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE, NM 87125-6666
Phone number: 505-923-6770
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