Miata Wallace, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

2760 Issued in NE

Practice address

1500 S 58TH St Ste 800
Lincoln, NE 68506-1407

Phone

(402) 483-8600

Fax

(402) 483-8689

NPI assigned

May 31, 2022

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in NE

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2022

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Nebraska Pulmonary Specialties LLCGroup PAC ID 3072412881, 28 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Bryan Medical Center Hospital, Lincoln, NE, CCN 280003
• CHI Health Nebraska Heart Hospital, Lincoln, NE, CCN 280128

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: miata.wallace.1@32348.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Nebraska Pulmonary Specialties LLC

  • Pulmonary Disease Physician
  • Lincoln, NE
  • NPI 1669728457
  Medicare reassignment Care Compare group
• Douglas R. Fiedler, MD, PC

  • Pulmonary Disease Physician
  • Lincoln, NE
  • NPI 1083640288
  NPD
• Jeffrey E Jarrett, MD, PC

  • Pulmonary Disease Physician
  • Lincoln, NE
  • NPI 1598907321
  NPD
• John F. Trapp, MD, PC

  • Pulmonary Disease Physician
  • Lincoln, NE
  • NPI 1548206477
  NPD
• Kevin J Reichmuth, MD, PC

  • Pulmonary Disease Physician
  • Lincoln, NE
  • NPI 1245416205
  NPD
• Pulmonary Medicine of Lincoln, PC

  • Pulmonary Disease Physician
  • Lincoln, NE
  • NPI 1336185248
  NPD
• William M Johnson, MD, PC

  • Pulmonary Disease Physician
  • Lincoln, NE
  • NPI 1063448660
  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Bryan Medical Center

  • General Acute Care Hospital
  • Lincoln, NE
  • NPI 1528006103
  Care Compare affiliation
• Bryan Medical Center

  • Clinical Medical Laboratory
  • Lincoln, NE
  • NPI 1689203077

  Hospital

  Care Compare affiliation
• Bryan Medical Center

  • Diagnostic Radiology Physician
  • Lincoln, NE
  • NPI 1699384370

  Hospital

  Care Compare affiliation
• Nebraska Heart Hospital

  • General Acute Care Hospital
  • Lincoln, NE
  • NPI 1699718437
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1653955200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1742860800000",
    "number": "1013656990",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1500 S 58TH ST STE 800",
            "city": "LINCOLN",
            "state": "NE",
            "postal_code": "685061407",
            "telephone_number": "402-483-8600",
            "fax_number": "402-483-8689"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1500 S 58TH ST STE 800",
            "city": "LINCOLN",
            "state": "NE",
            "postal_code": "685061407",
            "telephone_number": "402-483-8600",
            "fax_number": "402-483-8689"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MIATA",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-05-31",
        "last_updated": "2025-03-25",
        "certification_date": "2025-03-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NE",
            "license": "2760",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "miata.wallace.1@32348.direct.athenahealth.com",
            "affiliation": "N",
            "endpointDescription": "Direct Address",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "1500 S 58th St Ste 800",
            "city": "Lincoln",
            "state": "NE",
            "country_code": "US",
            "postal_code": "685061407",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Blanca Wallace
• Grant Meyer Wallace
• Jamieria Wallace
• Julie L Wallace
• Kathleen Wallace
• Sarah Rain Byrd Wallace
• Shealynn Wallace
• Trista Anne Wallace, CRNA
• Alaini Wallen, DO
• Marcia L Wallen, MS, RD, LMNT

• Physician Assistant in Lincoln, NE
• Providers in Lincoln, NE by specialty
• Physician Assistant in Nebraska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.