Provider Demographics
NPI:1891946240
Name:WALLACE, CEDRIC CHARLES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CEDRIC
Middle Name:CHARLES
Last Name:WALLACE
Suffix:
Gender:M
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 1:20 COOLIDGE PL
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-2543
Mailing Address - Country:US
Mailing Address - Phone:516-779-5996
Mailing Address - Fax:
Practice Address - Street 1:20 COOLIDGE PL
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-2543
Practice Address - Country:US
Practice Address - Phone:516-779-5996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-03
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012591363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant