Provider Demographics
NPI:1568693927
Name:WALLACE, ASHLEY B (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:B
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 1:1402 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-2415
Mailing Address - Country:US
Mailing Address - Phone:814-940-2000
Mailing Address - Fax:814-569-1878
Practice Address - Street 1:1402 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2415
Practice Address - Country:US
Practice Address - Phone:814-940-2000
Practice Address - Fax:814-569-1878
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant