Individual
JEFFREY W WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1601 WENTZVILLE PKWY STE 117, WENTZVILLE, MO 63385-3814
(636) 332-8477
Mailing address
112 PIPER HILL DR, FIRST FLOOR, SAINT PETERS, MO 63376-1690
(636) 441-3444
(636) 441-9832
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2005024101
MO
363AM0700X
Medical Physician Assistant
2005024101
MO
363AS0400X
Surgical Physician Assistant
2005024101
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2005024101
LICENSE
MO
Enumeration date
07/14/2007
Last updated
07/24/2025
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