Basic Information
| Provider Information | |||||||||
| NPI: | 1619179132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043845043 | ||||||||
| FaxNumber: | 7043848895 | ||||||||
| Practice Location | |||||||||
| Address1: | 10030 GILEAD RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280787545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048874530 | ||||||||
| FaxNumber: | 7048874531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 102472 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 102472 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2747736E | 01 | NC | MEDICARE PTAN | OTHER | 8101076 | 05 | NC | MEDICAID | 159XJ | 01 | NC | BCBS | OTHER |