Provider Demographics
NPI:1609264373
Name:WALLACE, ANYA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANYA
Middle Name:
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 1:309 S SHARON AMITY RD.
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211
Mailing Address - Country:US
Mailing Address - Phone:704-360-5018
Mailing Address - Fax:980-273-1102
Practice Address - Street 1:309 S SHARON AMITY RD.
Practice Address - Street 2:SUITE 206
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-360-5018
Practice Address - Fax:980-273-1102
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05473363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant