Provider Demographics
NPI:1700850674
Name:WALLACE, TIMOTHY (PA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 8TH AVE
Mailing Address - Street 2:#5F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-1555
Mailing Address - Country:US
Mailing Address - Phone:718-399-2527
Mailing Address - Fax:
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:BOX 56
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2056
Practice Address - Country:US
Practice Address - Phone:718-270-1554
Practice Address - Fax:718-270-4123
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004988-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant