Provider Demographics
NPI:1861631004
Name:WALLACE, DEANNA ELENA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:ELENA
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12553 GULF FWY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77034-4509
Mailing Address - Country:US
Mailing Address - Phone:281-481-8557
Mailing Address - Fax:281-481-2676
Practice Address - Street 1:7616 BRANFORD PL STE 320
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-3794
Practice Address - Country:US
Practice Address - Phone:819-801-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical