Provider Demographics
NPI:1265613855
Name:WALLACE, SCOTT ARTHUR (PA-C)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ARTHUR
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:PO BOX 15133
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0133
Mailing Address - Country:US
Mailing Address - Phone:919-470-5345
Mailing Address - Fax:
Practice Address - Street 1:3643 N ROXBORO ST
Practice Address - Street 2:DURHAM REGIONAL HOSPITAL EMERGENCY DEPARTMENT
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2702
Practice Address - Country:US
Practice Address - Phone:919-470-5345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-25
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant