Provider Demographics
NPI:1730596875
Name:WALLACE, CYNTHIA CATHERINE (PA)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:CATHERINE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5070 HIGHWAY A1A STE A
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-1229
Mailing Address - Country:US
Mailing Address - Phone:954-531-9433
Mailing Address - Fax:
Practice Address - Street 1:5070 HIGHWAY A1A STE A
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-1229
Practice Address - Country:US
Practice Address - Phone:954-531-9433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005406207N00000X
363AM0700X
FLPA9114207363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical