Provider Demographics
NPI:1811128010
Name:WALLACE, TRACEE MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TRACEE
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:TRACEE
Other - Middle Name:MARIE
Other - Last Name:HERMANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10551 HUNTERS WAY
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-5723
Mailing Address - Country:US
Mailing Address - Phone:505-573-1388
Mailing Address - Fax:
Practice Address - Street 1:5255 LOUGHBORO RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-2633
Practice Address - Country:US
Practice Address - Phone:202-537-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031280363AS0400X
NMPA2009-0015363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical