MEDICARE: SUMMIT PRIMARY CARE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1548143274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMIT PRIMARY CARE PLLC

Provider Business Mailing Address
First Line	:	13564 VILLAGE PARK DR UNIT O-355
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32837-7760
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13564 VILLAGE PARK DR UNIT O-355
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32837-7760
Country	:	US
Telephone Number	:	407-974-4056
Fax Number	:	407-550-7844

Authorized Official
Title or Position	:	OWNER
Name	:	GRACEMARIE ROSARIO WALLS
Credential	:	PA-C
Telephone Number	:	321-496-5717

Provider Enumeration Date	:	07/29/2025
Last Update Date	:	10/25/2025

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Directions to “SUMMIT PRIMARY CARE PLLC ” Practice Location

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