MEDICARE: WALLACE EDWIN WILSON PA-C

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	363A00000X	Physician Assistant	4053	GA

General Provider Information

NPI Number	:	1841279411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALLACE EDWIN WILSON PA-C

Provider Business Mailing Address
First Line	:	410 PEACHTREE PKWY STE 300
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30041-7407
Country	:	US
Telephone Number	:	404-255-1933
Fax Number	:	404-785-2822

Provider Business Practice Location Address
First Line	:	410 PEACHTREE PKWY STE 300
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30041-7407
Country	:	US
Telephone Number	:	404-255-1933
Fax Number	:	404-785-2822

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2006
Last Update Date	:	06/06/2022

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