Provider Demographics
NPI:1356918494
Name:WALLACE, CASSANDRA LEE (PA-C)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:LEE
Last Name:WALLACE
Suffix:
Gender:F
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:941-921-0986
Mailing Address - Fax:
Practice Address - Street 1:7250 BENEVA RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-2806
Practice Address - Country:US
Practice Address - Phone:941-921-0986
Practice Address - Fax:941-921-0989
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114232363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113768400Medicaid
FLPENDINGOtherMEDICARE