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Individual
LATOYA M. WALLACE
Active
Individual
LATOYA M. WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA9109974
FL
363AM0700X
Medical Physician Assistant
PA9109974
FL
363AS0400X
Surgical Physician Assistant
4254
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
ZA98W
BCBSFL
FL
Enumeration date
10/07/2008
Last updated
04/15/2020
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