Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 6346 | TX |
NPI | 1053426460 |
---|---|
Provider Name | Dr. Scott Wallis |
First Address | Hurst, TX 76053-3958 |
Second Address | Hurst, TX 76053-3958 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
47503 | (02) | TX |