Provider Demographics
NPI:1588946214
Name:WALLACE, MICAH R (PA-C)
Entity type:Individual
Prefix:MS
First Name:MICAH
Middle Name:R
Last Name:WALLACE
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:520 JEFFERSON AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-2538
Mailing Address - Country:US
Mailing Address - Phone:724-527-8060
Mailing Address - Fax:724-522-4002
Practice Address - Street 1:100 EXCELA HEALTH DR STE 102
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-9001
Practice Address - Country:US
Practice Address - Phone:724-804-1760
Practice Address - Fax:724-804-1762
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2018-12-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMA054581363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103167119Medicaid
PA103167119Medicaid