Provider Demographics
NPI:1871653345
Name:AMMON, WALLACE KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:KEITH
Last Name:AMMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-2297
Mailing Address - Country:US
Mailing Address - Phone:717-988-0000
Mailing Address - Fax:717-782-5716
Practice Address - Street 1:300 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331
Practice Address - Country:US
Practice Address - Phone:717-988-0000
Practice Address - Fax:717-782-5716
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100434OtherGEISINGER
PA7107935OtherAETNA
PA101445370Medicaid
PA2626996000OtherAMERIHEALTH 65 PA
MD891000OtherCAREFIRST MD BCBS
PA103042OtherJOHNS HOPKINS
PA1789885OtherHIGHMARK BLUE SHIELD
PA103042OtherJOHNS HOPKINS
PA099295Medicare PIN