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General NPI Number Information
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NPI Number | 1821342106
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Entity Type | Individual
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Provider Name | HEATHER A WALLACE DSC., PA-C
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Gender | Female
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Dates
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Enumeration Date | 11/07/2012
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Last Update Date | 12/10/2025
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Provider Practice Location Address
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Address Line | 915 E 1ST ST
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City | DULUTH
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State | MN
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Zip | 55805-2107
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Country | US
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Telephone | 218-249-6450
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Fax |
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Provider Business Mailing Address
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Address Line | 3066 SEARS RD
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City | SUGARCRK TWP
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State | OH
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Zip | 45370-7726
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Country | US
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Telephone |
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Fax |
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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 | PA61359713
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0110004235
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 15336
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License Number State | MN
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Taxonomy #4
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 029464
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License Number State | NY
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Taxonomy #5
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 25MP00742200
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License Number State | NJ
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Taxonomy #6
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 10004010A
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License Number State | IN
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Taxonomy #7
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.007882RX
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License Number State | OH
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Taxonomy #8
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 085.010935
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License Number State | IL
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