Provider Demographics
NPI:1538241815
Name:WALLACE, ELLIS J (PA-C)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:STE 1 D03
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31315
Mailing Address - Country:US
Mailing Address - Phone:912-435-6633
Mailing Address - Fax:912-435-5379
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-6633
Practice Address - Fax:912-435-5379
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002533363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00560436KMedicaid
GA97BBGTCMedicare ID - Type UnspecifiedMEDICARE