Provider Demographics
NPI:1518233931
Name:WALLACE, LEAH GYNELL (PA-C)
Entity Type:Individual
Prefix:PROF
First Name:LEAH
Middle Name:GYNELL
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:1347 BOSTON POST RD
Practice Address - Street 2:SUITE 106
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3475
Practice Address - Country:US
Practice Address - Phone:203-779-5207
Practice Address - Fax:203-779-5792
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2015-02-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT002731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008039969Medicaid
CTD400177730Medicare PIN