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General NPI Number Information
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NPI Number | 1225128069
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Entity Type | Individual
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Provider Name | ZICHARIEA Z WALLACE PA
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Gender | Female
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Dates
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Enumeration Date | 10/13/2006
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Last Update Date | 10/10/2011
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Provider Practice Location Address
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Address Line | 1000 N VILLAGE AVE. MERCY MEDICAL CENTER
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City | ROCKVILLE CENTRE
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State | NY
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Zip | 11570
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Country | US
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Telephone | 516-705-2525
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Fax | 516-705-6969
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Provider Business Mailing Address
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Address Line | 1003 STEELE BLVD
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City | BALDWIN
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State | NY
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Zip | 11510-4444
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Country | US
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Telephone | 718-367-0200
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Fax | 718-367-0222
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 010776
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License Number State | NY
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