Wallace, Ellis J

Wallace, Ellis J is an individual health care provider with primary practice located at 1061 Harmon Ave , Fort Stewart GA 31314-5641. He recently has only one registered license in Physician Assistants & Advanced Practice Nursing Providers / Medical, which is considered as his primary health care specialty. Wallace, Ellis J can be contacted via phone (912) 435-6633.

Contact Information

Primary practice address
1061 Harmon Ave Fort Stewart GA 31314-5641
Phone: (912) 435-6633
Fax: (912) 435-5379
Website:
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Health care specialties

SpecialtyCodeLicense #State
Physician Assistants & Advanced Practice Nursing Providers / Medical 363AM0700X 002533 Georgia

Profile Details

NPI number 1538241815
LBN Legal business name Wallace, Ellis J
Credentials Physician's Assistant Certified (PA-C)
Entity Individual
Sole proprietor 1 No
Enumeration date Oct 19th, 2006
Last updated Mar 10th, 2011 - about 13 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1538241815 NPPES
Georgia MEDICAID 00560436K

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