Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | DC0218140 | CA |
NPI | 1790847937 |
---|---|
Provider Name | Wallace Troy Stevens |
First Address | Dixon, CA 95620-2022 |
Second Address | Dixon, CA 95620-2026 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2006 |
Last Update Date | 27/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
680461726 | TAX ID (01) | CA |
DC0218140 | (02) | CA |