Provider Demographics
NPI:1619179132
Name:WALLACE, CONNIE SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:SUE
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-5043
Mailing Address - Fax:704-384-8895
Practice Address - Street 1:10030 GILEAD RD STE 201
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7545
Practice Address - Country:US
Practice Address - Phone:704-887-4530
Practice Address - Fax:704-887-4531
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102472363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2747736EOtherMEDICARE PTAN
NC8101076Medicaid
NC159XJOtherBCBS