Provider Demographics
NPI:1881634327
Name:WALLACE, DEBBIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBBIE
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
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 1:2235 VENETIAN COURT, SUITE 1
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109
Mailing Address - Country:US
Mailing Address - Phone:239-596-9337
Mailing Address - Fax:239-596-9466
Practice Address - Street 1:2235 VENETIAN COURT, SUITE 1
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109
Practice Address - Country:US
Practice Address - Phone:239-596-9337
Practice Address - Fax:239-596-9466
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102648363AS0400X, 363AM0700X
TXPA02505363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83N935Medicare ID - Type Unspecified
K5855Medicare UPIN
TXP05366Medicare UPIN
TX85N315Medicare ID - Type Unspecified