Provider Demographics
NPI:1205959285
Name:WALLIS, RACHEL ANNA (RPA-C, MS)
Entity type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:ANNA
Last Name:WALLIS
Suffix:
Gender:F
Credentials:RPA-C, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24915 SHILOH AVE # 2
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-2640
Mailing Address - Country:US
Mailing Address - Phone:917-226-7900
Mailing Address - Fax:
Practice Address - Street 1:24915 SHILOH AVE # 2
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-2640
Practice Address - Country:US
Practice Address - Phone:917-226-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0127721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant