Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208800000X | Urologist | 0101242596 | VA |
NPI | 1033328703 |
---|---|
Provider Name | Timothy J Wallace |
First Address | Richmond, VA 23291-1734 |
Second Address | Richmond, VA 23298-5017 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/05/2007 |
Last Update Date | 26/03/2019 |