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Individual
KELLEYAYN WALLACE
Active
Individual
KELLEYAYN WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
011509
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02578343
—
NY
01
—
1366535940
GROUP NPI
NY
01
—
7082043
AETNA
NY
01
—
CF8438
MEDICARE RAILROAD
NY
01
—
G0183898590
EXCELLUS
—
Enumeration date
09/26/2006
Last updated
12/09/2015
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