Individual
RAY L WALLACE JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
4425 PAULSEN ST, SAVANNAH, GA 31405-3662
(912) 355-6615
(912) 351-0645
Mailing address
4425 PAULSEN ST, SAVANNAH, GA 31405-3662
(912) 355-6615
(912) 351-0645
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
000935
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
203066747A
—
GA
05
—
203066747B
—
GA
Enumeration date
06/23/2006
Last updated
02/23/2021
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