Provider Demographics
NPI:1518249093
Name:WALLACE, ANNA EVERETT (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANNA
Middle Name:EVERETT
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 ABERCORN ST STE D
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-6915
Mailing Address - Country:US
Mailing Address - Phone:912-232-9700
Mailing Address - Fax:912-748-0270
Practice Address - Street 1:5356 REYNOLDS ST STE 201
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6019
Practice Address - Country:US
Practice Address - Phone:912-232-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003114943CMedicaid
GA202I976947Medicare PIN