Individual
MIKAYLA WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
355 GRAND ST, JERSEY CITY, NJ 07302-4321
(201) 915-2000
Mailing address
113 HOFSTRA UNIVERSITY RM 231, HEMPSTEAD, NY 11549-1925
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
25MP00684600
NJ
363A00000X
Physician Assistant
Primary
—
—
Other
Enumeration date
12/20/2021
Last updated
07/30/2024
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