Individual
CONNIE SUE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
10030 GILEAD RD STE 201, HUNTERSVILLE, NC 28078-7545
(704) 887-4530
(704) 887-4531
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(704) 384-5043
(704) 384-8895
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
102472
NC
363AM0700X
Medical Physician Assistant
102472
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
159XJ
BCBS
NC
01
—
2747736E
MEDICARE PTAN
NC
05
—
8101076
—
NC
Enumeration date
06/05/2007
Last updated
08/23/2022
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