Healthcare Provider Details

I. General information

NPI: 1427321041
Provider Name (Legal Business Name): MATTHEW ALEXANDER WALLACE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2012
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 5TH AVE FL 3
NEW YORK NY
10017-6145
US

IV. Provider business mailing address

5047 SUNCATCHER DR
WESLEY CHAPEL FL
33545-3234
US

V. Phone/Fax

Practice location:
  • Phone: 888-663-6331
  • Fax: 415-252-7176
Mailing address:
  • Phone: 616-318-9649
  • Fax: 616-333-8159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number035105
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: