Provider Demographics
NPI:1700322468
Name:WALLACE, TEMEKA (PA)
Entity Type:Individual
Prefix:MRS
First Name:TEMEKA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SUSAN TART RD
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-5506
Mailing Address - Country:US
Mailing Address - Phone:910-892-8892
Mailing Address - Fax:910-892-1063
Practice Address - Street 1:800 SUSAN TART RD
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-5506
Practice Address - Country:US
Practice Address - Phone:910-892-8892
Practice Address - Fax:910-892-1063
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001006945363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical