Healthcare Provider Details

I. General information

NPI: 1245328285
Provider Name (Legal Business Name): SARAH WALLACE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 PATTERSON ST SUITE 311
NASHVILLE TN
37203-1562
US

IV. Provider business mailing address

2400 PATTERSON ST SUITE 311
NASHVILLE TN
37203-1562
US

V. Phone/Fax

Practice location:
  • Phone: 615-342-6830
  • Fax: 615-342-6836
Mailing address:
  • Phone: 615-342-6830
  • Fax: 615-342-6836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1517
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: