MR. PHILLIP TYLER WALLACE (NPI# 1821647447) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1821647447 |
| Entity Type | Individual |
| Full Name | MR. PHILLIP TYLER WALLACE |
| Credential | APRN |
| Practice Address |
1325 San Marco Blvd Ste 300 Jacksonville FL 32207-8567 |
| Mailing Address |
2728 Herschel St Jacksonville FL 32205-8115 |
| Practice Telephone | 9042536910 |
| Mailing Telephone | 9045884442 |
| Enumeration Date | 2019-09-06 |
| Last Update Date | 2019-09-06 |
| Gender Code | M |
| Is Sole Proprietor | Y |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 363LA2100X |
Nurse Practitioner Specialization: Acute Care |
APRN11003275 | FL | Physician Assistants & Advanced Practice Nursing Providers |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1083759930 | Phillip Wendell Wallace | Dentist | 36001 Euclid Ave Ste A15, Willoughby, OH 44094-4643 | 2007-02-20 |
| Street Address |
1325 SAN MARCO BLVD STE 300 |
| City | JACKSONVILLE |
| State | FL |
| Zip Code | 32207-8567 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1275890402 | Amit K Babbar | Internal Medicine | 1325 San Marco Blvd Ste 300, Jacksonville, FL 32207-8567 | 2012-04-12 |
| 1245894005 | Alexa Dyan Paik | Nurse Practitioner | 1325 San Marco Blvd Ste 300, Jacksonville, FL 32207-8567 | 2019-04-26 |
| 1164989596 | Cody Lee Perrigo | Nurse Practitioner | 1325 San Marco Blvd Ste 300, Jacksonville, FL 32207-8567 | 2019-02-21 |
| 1073022042 | James Daxton Turner | Nurse Practitioner | 1325 San Marco Blvd Ste 300, Jacksonville, FL 32207-8567 | 2017-09-21 |
| 1558705194 | William Taylor Palfrey Jr. | Internal Medicine | 1325 San Marco Blvd Ste 300, Jacksonville, FL 32207-8567 | 2013-04-25 |
| 1790042513 | Eddy Gutierrez | Internal Medicine | 1325 San Marco Blvd Ste 300, Jacksonville, FL 32207-8567 | 2012-04-18 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1033768981 | North Florida Pediatrics, Pa | Pediatrics | 4501 Atlantic Boulevard, Jacksonville, FL 32207 | 2019-09-04 |
| 1578117024 | Pragna Mukesh Dholakia | Nurse Practitioner | 2624 Atlantic Blvd., Jacksonville, FL 32207 | 2019-08-01 |
| 1821653601 | The Adoption Authority, Inc. | Case Management | 4940 Emerson Street, Suite 103, Jacksonville, FL 32207 | 2019-05-07 |
| 1255896080 | Elizabeth Lynn Houghton | Social Worker | Sulzbacher Village, 904-720-2079, Jacksonville, FL 32207 | 2019-02-06 |
| 1902374630 | Guilherme Jose Agnoletto | Neurological Surgery | 800 Prudential Drive Weaver Tower 11th Floor, Jacksonville, FL 32207 | 2018-11-12 |
| 1073008504 | Pavilion Infusion Therapy Inc | Durable Medical Equipment & Medical Supplies | 1301 Palm Avenue, Suite 220, Jacksonville, FL 32207 | 2018-06-27 |
| 1346733185 | Dueseason1 | Registered Nurse | 4058 Saint Augustine Rd, Jacksonville, FL 32207 | 2018-06-06 |
| 1164911913 | Eric Lang Poovey | Nurse Practitioner | Baptist Heart Specialists, 836 Prudential Drive Suite 1700, Jacksonville, FL 32207 | 2018-05-08 |
| 1902311046 | Spring Park Pharmacy LLC | Durable Medical Equipment & Medical Supplies | 3851 Emerson St Ste 13, Jacksonville, FL 32207 | 2017-12-12 |
| 1295247948 | Emed Urgent and Primary Care Pa | Clinic/Center | 2570 Atlantic Boulevard, Jacksonville, FL 32207 | 2017-11-02 |
| Find all providers in zip 32207 | ||||
| Taxonomy Code | 363LA2100X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Nurse Practitioner |
| Specialization | Acute Care |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1306443916 | Simmy Regin Varghese | Nurse Practitioner | 1613 Hammock Grove Ln, Jacksonville, FL 32225-5575 | 2020-10-06 |
| 1265917124 | Sandra Jayussi | Nurse Practitioner | 7406 Fullerton Ave, Jacksonville, FL 32256 | 2018-09-26 |
| 1427563980 | William Phillips | Nurse Practitioner | 1325 San Marco Blvd Bldg Suite300, Jacksonville, FL 32207-8568 | 2017-12-06 |
| 1366977902 | Annette Faulkner Wall | Nurse Practitioner | 14601 Swansea Ct, Jacksonville, FL 32258-4446 | 2017-04-20 |
| 1730457565 | Tressie Brooks | Nurse Practitioner | 4203 Belfort Rd Ste 108, Jacksonville, FL 32216-1411 | 2011-12-07 |
| 1346563129 | Brooke Leigh Mcduffie | Nurse Practitioner | 3115 Spring Glen Rd, Suite 505, Jacksonville, FL 32207-5978 | 2010-03-08 |
| 1558536490 | Jacquelyn Danette Cannon | Nurse Practitioner | 1200 Riverplace Blvd 620, Jacksonville, FL 32207-1803 | 2008-04-22 |
| 1003969627 | Mike J Primeaux | Nurse Practitioner | 10601 San Jose Blvd Ste 208, Jacksonville, FL 32257-8203 | 2007-01-18 |
| 1700819372 | Paula F New | Nurse Practitioner | 3221 Henderson Dr, Jacksonville, NC 28546-5251 | 2006-07-08 |
| 1114972841 | Roxanna A Mcdonald | Nurse Practitioner | 1947 Morningside St, Jacksonville, FL 32205-9390 | 2006-05-23 |
| Find all providers in JACKSONVILLE | ||||
| City | JACKSONVILLE |
| Zip Code | 32207 |
Please comment or provide details below to improve the information on MR. PHILLIP TYLER WALLACE.
| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.