Provider Demographics
NPI:1366877060
Name:WALLACE, MARGARET L (PA)
Entity type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:L
Last Name:WALLACE
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Gender:F
Credentials:PA
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Mailing Address - Street 1:22100 GREENFIELD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2550
Mailing Address - Country:US
Mailing Address - Phone:248-968-4811
Mailing Address - Fax:248-968-4822
Practice Address - Street 1:22100 GREENFIELD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2550
Practice Address - Country:US
Practice Address - Phone:248-968-4811
Practice Address - Fax:248-968-4822
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
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Provider Licenses
StateLicense IDTaxonomies
MI5601006812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant