Provider Demographics
NPI:1104130426
Name:WALLACE, BRENDA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3142 HORIZON RD STE 209
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-7802
Mailing Address - Country:US
Mailing Address - Phone:972-771-2018
Mailing Address - Fax:972-772-4654
Practice Address - Street 1:3142 HORIZON RD STE 209
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7802
Practice Address - Country:US
Practice Address - Phone:972-771-2018
Practice Address - Fax:972-772-4654
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06792363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX482354YKP5Medicare PIN