Provider Demographics
NPI:1326680331
Name:WALLACE, EMILY (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:LAZZAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1320 W STATE ST STE 3A
Mailing Address - Street 2:
Mailing Address - City:BELDING
Mailing Address - State:MI
Mailing Address - Zip Code:48809-9245
Mailing Address - Country:US
Mailing Address - Phone:616-794-1810
Mailing Address - Fax:
Practice Address - Street 1:1320 W STATE ST STE 3A
Practice Address - Street 2:
Practice Address - City:BELDING
Practice Address - State:MI
Practice Address - Zip Code:48809-9245
Practice Address - Country:US
Practice Address - Phone:616-794-1810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant