Individual
MR. CEDRIC CHARLES WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
20 COOLIDGE PL, FREEPORT, NY 11520-2543
(516) 779-5996
Mailing address
20 COOLIDGE PL, FREEPORT, NY 11520-2543
(516) 779-5996
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
012591
NY
Other
Enumeration date
10/03/2008
Last updated
04/02/2021
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