Provider Demographics
NPI:1487909511
Name:WALLACE, JOHN DAVID (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DAVID
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:601 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-9383
Mailing Address - Country:US
Mailing Address - Phone:231-536-2206
Mailing Address - Fax:231-536-7150
Practice Address - Street 1:601 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9383
Practice Address - Country:US
Practice Address - Phone:231-536-2206
Practice Address - Fax:231-536-7150
Is Sole Proprietor?:No
Enumeration Date:2012-07-15
Last Update Date:2022-09-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006422363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant