Provider Demographics
NPI:1073764114
Name:WALLACE, LATOYA M (PA)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:M
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 1:1010 N 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-3370
Mailing Address - Country:US
Mailing Address - Phone:410-908-7714
Mailing Address - Fax:850-203-4629
Practice Address - Street 1:1010 N 12TH AVE STE 125
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-3315
Practice Address - Country:US
Practice Address - Phone:850-361-8598
Practice Address - Fax:850-203-4629
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4254363AS0400X
FLPA9109974363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZA98WOtherBCBSFL