# RAY L WALLACE JR.

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1720014624
- **Gender:** Man
- **Credential:** PA

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363A00000X | Physician Assistant | 000935 | GA | Yes |

## Other

- **Enumeration date:** 06/23/2006
- **Last updated:** 02/23/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 203066747A | — | GA |
| 05 | — | 203066747B | — | GA |