Provider Demographics
NPI:1841583788
Name:WALLACE, RICHARD JEREMY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JEREMY
Last Name:WALLACE
Suffix:
Gender:M
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 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-1529
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:803-259-3250
Practice Address - Street 1:13649 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:SC
Practice Address - Zip Code:29853
Practice Address - Country:US
Practice Address - Phone:803-266-0060
Practice Address - Fax:803-266-0042
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2920OtherMEDICAL LICENSE
SCSCE705OtherMEDICARE
SC3559PAMedicaid