Provider Demographics
NPI:1720014624
Name:WALLACE, RAY L JR (PA)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:L
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4425 PAULSEN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-3662
Mailing Address - Country:US
Mailing Address - Phone:912-355-6615
Mailing Address - Fax:912-351-0645
Practice Address - Street 1:4425 PAULSEN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-3662
Practice Address - Country:US
Practice Address - Phone:912-355-6615
Practice Address - Fax:912-351-0645
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA000935363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA203066747BMedicaid
GA203066747AMedicaid
GA203066747AMedicaid
GA203066747BMedicaid
GA97WCGZLMedicare PIN