Individual
MS. MICAH R WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
100 EXCELA HEALTH DR STE 102, LATROBE, PA 15650-9001
(724) 804-1760
(724) 804-1762
Mailing address
520 JEFFERSON AVE, SUITE 400, JEANNETTE, PA 15644-2538
(724) 527-8060
(724) 522-4002
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
MA054581
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
103167119
—
PA
Enumeration date
09/20/2011
Last updated
12/21/2018
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