Provider Demographics
NPI:1942497631
Name:WALLACE, ROBIN E (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:E
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 KEMPSVILLE CIR STE 325A
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3933
Mailing Address - Country:US
Mailing Address - Phone:757-354-2885
Mailing Address - Fax:757-917-5141
Practice Address - Street 1:6160 KEMPSVILLE CIR STE 325A
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3933
Practice Address - Country:US
Practice Address - Phone:757-354-2885
Practice Address - Fax:757-917-5141
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002610363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10115900POtherOPTIMA HEALTH
VA1942497631Medicaid
VAPAROtherUSA MANAGED CARE
VAPAROtherCORVEL
VA-022OtherTRICARE/CHAMPUS
NC8101130Medicaid
VAPAROtherUSA MANAGED CARE
NC8101130Medicaid