Reginald Wallace, PA-C

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

PA02096 Issued in TX

Practice address

12603 Southwest Fwy
Suite 335
Stafford, TX 77477-3820

Phone

(713) 398-7337

NPI assigned

Jan 8, 2013

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1357603200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1357603200000",
    "number": "1265779441",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3231 TRUESDALE DR",
            "city": "MISSOURI CITY",
            "state": "TX",
            "postal_code": "774594947",
            "telephone_number": "713-398-7337"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12603 SOUTHWEST FWY",
            "address_2": "SUITE 335",
            "city": "STAFFORD",
            "state": "TX",
            "postal_code": "774773820",
            "telephone_number": "713-398-7337"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "REGINALD",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-01-08",
        "last_updated": "2013-01-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "TX",
            "license": "PA02096",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Medical Physician Assistant in Stafford, TX
• Providers in Stafford, TX by specialty
• Medical Physician Assistant in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.