Provider Demographics
NPI:1427321041
Name:WALLACE, MATTHEW ALEXANDER (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7497 BERNARD DR
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-1552
Mailing Address - Country:US
Mailing Address - Phone:616-318-9649
Mailing Address - Fax:
Practice Address - Street 1:7497 BERNARD DR
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-1552
Practice Address - Country:US
Practice Address - Phone:616-318-9649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical