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Dr. Logan Lauderdale Wallace, MD
Student in an Organized Health Care Education/Training Program in Fort Gordon, Georgia
NPI 1811567100

Logan Lauderdale Wallace is a Student in an Organized Health Care Education/Training Program based in Fort Bragg, GA. Logan Lauderdale Wallace practices in Fort Gordon, GA and has the professional credentials of MD. The NPI Number for Logan Lauderdale Wallace is 1811567100 and holds a License No. 2022-02887 (Georgia).

The current practice location address for Logan Lauderdale Wallace is 300 East Hospital Road, Fort Gordon, GA and can be reached out via phone at 707-786-5811.

Location: 300 East Hospital Road, Fort Gordon, GA, 28307
Profile Details Legacy Identifiers Practice Address Mailing Address Primary Taxonomy
person
Provider Profile Details
NPI Number
1811567100
Provider Name
Logan Lauderdale Wallace
Credential
MD
Provider Entity Type
Individual
Gender
Male
Address
300 East Hospital Road, Fort Gordon, GA, 28307
Phone Number
707-786-5811
Fax Number
Provider Enumeration Date
06/29/2021
Last Update Date
03/10/2024
institution
Provider Business Practice Location Address Details
Address
300 East Hospital Road
City
Fort Gordon
State
Georgia
Zip
30905-5650
Phone Number
707-786-5811
Fax Number
person
Provider Business Mailing Address Details
Address
300 East Hospital Road
City
Fort Gordon
State
Georgia
Zip
30905-5650
Phone Number
707-786-5811
Fax Number
person
Provider's Taxonomy Details 1
Type
Allopathic & Osteopathic Physicians
Classification
General Practice
Speciality
-
Taxonomy
208D00000X
License No.
()
Definition
Definition to come...
person
Provider's Taxonomy Details 2
Type
Student, Health Care
Classification
Student in an Organized Health Care Education/Training Program
Speciality
-
Taxonomy
390200000X
License No.
2022-02887 (North Carolina)
Definition
An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care.
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