Provider Demographics
NPI:1851713952
Name:WALLACE, STEVEN GREGORY JR (PA)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:GREGORY
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:PA
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5026 FAIRFAX DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:511 W ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-7116
Practice Address - Country:US
Practice Address - Phone:813-659-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9107761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant