Wallace, William Jacob

Wallace, William Jacob is an sole proprietor health care provider with primary practice located at 105 S Willow Ave , Cookeville TN 38501-4667. He recently has 2 registered licenses in different health care specialties including Physician Assistants & Advanced Practice Nursing Providers / Medical, Physician Assistants & Advanced Practice Nursing Providers / Surgical. Physician Assistants & Advanced Practice Nursing Providers / Surgical is his primary health care specialty. Wallace, William Jacob can be contacted via phone (931) 372-7716.

Contact Information

Primary practice address
105 S Willow Ave Cookeville TN 38501-4667
Phone: (931) 372-7716
Fax: (931) 372-0087
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Physician Assistants & Advanced Practice Nursing Providers / Medical 363AM0700X 2743 Tennessee
Physician Assistants & Advanced Practice Nursing Providers / Surgical 363AS0400X PA2743 Tennessee

Profile Details

NPI number 1992183412
LBN Legal business name Wallace, William Jacob
Credentials Physician Assistant (PA)
Entity Individual
Sole proprietor 1 Yes
Enumeration date May 16th, 2015
Last updated Aug 27th, 2020 - about 4 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1992183412 NPPES
Tennessee MEDICAID Q015216

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