# DR. HEATHER A WALLACE

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

## Provider details

- **NPI number:** 1821342106
- **Gender:** F
- **Credential:** DSC., PA-C

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363A00000X | Physician Assistant | 0110004235 | VA | — |
| 363A00000X | Physician Assistant | 10004010A | IN | — |
| 363A00000X | Physician Assistant | 50.007882RX | OH | — |
| 363AS0400X | Surgical Physician Assistant | 029464 | NY | — |
| 363AS0400X | Surgical Physician Assistant | 085.010935 | IL | — |
| 363AS0400X | Surgical Physician Assistant | 15336 | MN | Yes |
| 363AS0400X | Surgical Physician Assistant | 25MP00742200 | NJ | — |
| 363AS0400X | Surgical Physician Assistant | PA61359713 | WA | — |

## Other

- **Enumeration date:** 11/07/2012
- **Last updated:** 12/10/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 233690187 | MEDICARE PTAN | IN |
| 05 | — | 300077904 | — | IN |