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General NPI Number Information
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NPI Number | 1649479171
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Entity Type | Individual
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Provider Name | JEFFREY W WALLACE PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/14/2007
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Last Update Date | 07/24/2025
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Provider Practice Location Address
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Address Line | 1601 WENTZVILLE PKWY STE 117
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City | WENTZVILLE
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State | MO
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Zip | 63385-3814
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Country | US
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Telephone | 636-332-8477
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Fax |
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Provider Business Mailing Address
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Address Line | 112 PIPER HILL DR FIRST FLOOR
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City | SAINT PETERS
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State | MO
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Zip | 63376-1690
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Country | US
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Telephone | 636-441-3444
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Fax | 636-441-9832
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 2005024101
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 2005024101
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2005024101
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License Number State | MO
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