Provider Demographics
NPI:1356766620
Name:WALLS, GRACEMARIE ROSARIO (PA-C)
Entity type:Individual
Prefix:
First Name:GRACEMARIE
Middle Name:ROSARIO
Last Name:WALLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 N ALAFAYA TRAIL
Mailing Address - Street 2:SUITE 206 PMB1066
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7665
Mailing Address - Country:US
Mailing Address - Phone:321-496-5717
Mailing Address - Fax:
Practice Address - Street 1:626 N ALAFAYA TRL STE 206
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4353
Practice Address - Country:US
Practice Address - Phone:321-496-5717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9108066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant