Provider Demographics
NPI:1851614739
Name:WALLACE, CARRIE ESTHER (PA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ESTHER
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ESTHER
Other - Last Name:IVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 S COLUMBIA RD
Mailing Address - Street 2:PO BOX 6002
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4032
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:
Practice Address - Street 1:1000 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4032
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND995363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant