Provider Demographics
NPI:1831290717
Name:WALLACE, KELLEYAYN (PA)
Entity type:Individual
Prefix:
First Name:KELLEYAYN
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 1:2080 CLINTON AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618
Mailing Address - Country:US
Mailing Address - Phone:585-271-2800
Mailing Address - Fax:585-271-0375
Practice Address - Street 1:2080 CLINTON AVE SOUTH
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618
Practice Address - Country:US
Practice Address - Phone:585-271-2800
Practice Address - Fax:585-271-0375
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCF8438OtherMEDICARE RAILROAD
NY7082043OtherAETNA
G0183898590OtherEXCELLUS
NY02578343Medicaid
NY1366535940OtherGROUP NPI
NY7082043OtherAETNA