Provider Demographics
NPI:1245328285
Name:WALLACE, SARAH (PA)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 PATTERSON ST
Mailing Address - Street 2:SUITE 311
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1562
Mailing Address - Country:US
Mailing Address - Phone:615-342-6830
Mailing Address - Fax:615-342-6836
Practice Address - Street 1:2400 PATTERSON ST
Practice Address - Street 2:SUITE 311
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1562
Practice Address - Country:US
Practice Address - Phone:615-342-6830
Practice Address - Fax:615-342-6836
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNPA1517363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6025ZMedicare ID - Type Unspecified
FLQ52000Medicare UPIN