Provider Demographics
NPI:1356399828
Name:WALLACE, TERRELL RICHARD JR (PA C)
Entity type:Individual
Prefix:MR
First Name:TERRELL
Middle Name:RICHARD
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:207 ESPLANADE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088
Mailing Address - Country:US
Mailing Address - Phone:478-922-3061
Mailing Address - Fax:478-953-5406
Practice Address - Street 1:136 SOUTH HOUSTON LAKE ROAD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-953-1020
Practice Address - Fax:478-953-5406
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA002665363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3326OtherMCR RR
P00162033OtherMCR RR
97BBDDZMedicare ID - Type Unspecified
S52432Medicare UPIN
97WCCTDMedicare ID - Type Unspecified