Provider Demographics
NPI:1518249838
Name:WALLACE, AMANDA DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DANIEL
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:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:655 JESSE JEWELL PKWY SE STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3854
Practice Address - Country:US
Practice Address - Phone:770-532-7092
Practice Address - Fax:770-536-0383
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6247363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003114911IMedicaid
GA003206458EMedicaid
GA003114911GMedicaid
GA04144822OtherAMERIGROUP
GA202I979469OtherMEDICARE PTAN