Provider Demographics
NPI:1992183412
Name:WALLACE, WILLIAM JACOB (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JACOB
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2498
Mailing Address - Country:US
Mailing Address - Phone:931-528-1992
Mailing Address - Fax:931-526-4381
Practice Address - Street 1:105 S WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4667
Practice Address - Country:US
Practice Address - Phone:931-372-7716
Practice Address - Fax:931-372-0087
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-16
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2743363AM0700X
TNPA2743363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ015216Medicaid