Basic Information
| Provider Information | |||||||||
| NPI: | 1942497631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6160 KEMPSVILLE CIR STE 325A | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573542885 | ||||||||
| FaxNumber: | 7579175141 | ||||||||
| Practice Location | |||||||||
| Address1: | 6160 KEMPSVILLE CIR STE 325A | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573542885 | ||||||||
| FaxNumber: | 7579175141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110002610 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 10115900P | 01 | VA | OPTIMA HEALTH | OTHER | 1942497631 | 05 | VA | MEDICAID | PAR | 01 | VA | USA MANAGED CARE | OTHER | PAR | 01 | VA | CORVEL | OTHER | -022 | 01 | VA | TRICARE/CHAMPUS | OTHER | 8101130 | 05 | NC | MEDICAID |