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1164674743
MARTY DALE WALLACE
JOHNSON CITY, TN
NPI
1164674743
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Entity Type
Individual
Gender
Male
Sole Proprietor ?
No
Primary Taxonomy
367500000X Nurse Anesthetist, Certified Registered
(Licence: TN APN13700)
Enumeration Date
2008-10-15
Last Update Date
2009-11-20
Business Address
-- MARTY DALE WALLACE CRNA
1114 SUNSET DR SUITE 4
JOHNSON CITY, TN 37604-2969
Phone number: 423-283-0776
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Mailing Address
-- MARTY DALE WALLACE CRNA
PO BOX 3727
JOHNSON CITY, TN 37602-3727
Phone number: 423-283-0776
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