Healthcare Provider Details

I. General information

NPI: 1649479171
Provider Name (Legal Business Name): JEFFREY W WALLACE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2007
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WENTZVILLE PKWY STE 117
WENTZVILLE MO
63385-3814
US

IV. Provider business mailing address

112 PIPER HILL DR FIRST FLOOR
SAINT PETERS MO
63376-1690
US

V. Phone/Fax

Practice location:
  • Phone: 636-332-8477
  • Fax:
Mailing address:
  • Phone: 636-441-3444
  • Fax: 636-441-9832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2005024101
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2005024101
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2005024101
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: