Provider Demographics
NPI:1700068020
Name:WALLACE, MOLLEE JOHANSEN (PA-C)
Entity type:Individual
Prefix:MS
First Name:MOLLEE
Middle Name:JOHANSEN
Last Name:WALLACE
Suffix:
Gender:F
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 1:1925 W JOHN CARPENTER FWY
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3224
Mailing Address - Country:US
Mailing Address - Phone:972-292-7158
Mailing Address - Fax:877-292-2247
Practice Address - Street 1:1925 W JOHN CARPENTER FWY
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3224
Practice Address - Country:US
Practice Address - Phone:972-292-7158
Practice Address - Fax:877-292-2247
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02519363A00000X
TXPA02159363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02519OtherLICENSE