Provider Demographics
NPI:1841279411
Name:WILSON, WALLACE EDWIN (PA-C)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:EDWIN
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:410 PEACHTREE PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7407
Mailing Address - Country:US
Mailing Address - Phone:404-255-1933
Mailing Address - Fax:404-785-2822
Practice Address - Street 1:410 PEACHTREE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7407
Practice Address - Country:US
Practice Address - Phone:404-255-1933
Practice Address - Fax:404-785-2822
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant