Provider Demographics
NPI:1063746667
Name:WALLACE, JARED LEE (PA-C)
Entity type:Individual
Prefix:MR
First Name:JARED
Middle Name:LEE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:43783 KENAI SPUR HWY
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-9708
Mailing Address - Country:US
Mailing Address - Phone:907-283-9116
Mailing Address - Fax:907-283-9122
Practice Address - Street 1:43783 KENAI SPUR HWY
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611
Practice Address - Country:US
Practice Address - Phone:907-283-9116
Practice Address - Fax:907-283-9122
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2023-03-07
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020379Medicaid
AKMW2082030OtherDEA LICENSE