Provider Demographics
NPI:1649272378
Name:WALLACE, ERIN MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:ERIN
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ERIN
Other - Middle Name:MARIE
Other - Last Name:RUTKOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:651 COLLIERS WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5055
Mailing Address - Country:US
Mailing Address - Phone:304-723-4700
Mailing Address - Fax:304-723-4719
Practice Address - Street 1:651 COLLIERS WAY STE 201
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5055
Practice Address - Country:US
Practice Address - Phone:043-723-4700
Practice Address - Fax:304-734-4719
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003119L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical