Individual
CASSANDRA LEE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
7250 BENEVA RD, SARASOTA, FL 34238-2806
(941) 921-0986
(941) 921-0989
Mailing address
3300 S FISKE BLVD, ROCKLEDGE, FL 32955-4306
(941) 921-0986
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA9114232
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
113768400
—
FL
01
—
PENDING
MEDICARE
FL
Enumeration date
06/08/2021
Last updated
04/05/2022
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