Provider Demographics
NPI:1700068020
Name:WALLACE, MOLLEE JOHANSEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MOLLEE
Middle Name:JOHANSEN
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 1:26265 NORTHWEST FWY
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-1760
Mailing Address - Country:US
Mailing Address - Phone:281-758-0092
Mailing Address - Fax:
Practice Address - Street 1:26265 NORTHWEST FWY
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-1760
Practice Address - Country:US
Practice Address - Phone:281-758-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02519OtherLICENSE