Provider Demographics
NPI:1225128069
Name:WALLACE, ZICHARIEA Z (PA)
Entity Type:Individual
Prefix:
First Name:ZICHARIEA
Middle Name:Z
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1003 STEELE BLVD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4444
Mailing Address - Country:US
Mailing Address - Phone:718-367-0200
Mailing Address - Fax:718-367-0222
Practice Address - Street 1:1000 N VILLAGE AVE.
Practice Address - Street 2:MERCY MEDICAL CENTER
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570
Practice Address - Country:US
Practice Address - Phone:516-705-2525
Practice Address - Fax:516-705-6969
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY010776363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical