Individual
DR. HEATHER A WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DSC., PA-C
Contact information
Practice address
915 E 1ST ST, DULUTH, MN 55805-2107
(218) 249-6450
Mailing address
3066 SEARS RD, SUGARCRK TWP, OH 45370-7726
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
0110004235
VA
363A00000X
Physician Assistant
10004010A
IN
363A00000X
Physician Assistant
50.007882RX
OH
363AS0400X
Surgical Physician Assistant
029464
NY
363AS0400X
Surgical Physician Assistant
085.010935
IL
363AS0400X
Surgical Physician Assistant
Primary
15336
MN
363AS0400X
Surgical Physician Assistant
25MP00742200
NJ
363AS0400X
Surgical Physician Assistant
PA61359713
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
233690187
MEDICARE PTAN
IN
05
—
300077904
—
IN
Enumeration date
11/07/2012
Last updated
12/10/2025
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