NPIMap

Individual provider Active NPI

Colby Rip Wallace, PA

  • Physician Assistant
  • Henderson, NC
National Provider Identifier
1396477840
Registry record updated Sep 27, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
0010-12596 Issued in NC
Practice address
566 Ruin Creek Rd
Henderson, NC 27536-2927
Phone
(919) 461-0017
NPI assigned
Jun 24, 2022
Last updated
Sep 27, 2023By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 27, 2023

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 0010-12596 NC Primary

Addresses

Primary practice location

566 Ruin Creek Rd
Henderson, NC 27536-2927

Mailing address

1218 Maroon Dr
Durham, NC 27713-8233
Phone (702) 596-9122

Other practice location 1

781 Avent Ferry Rd Ste 102
Holly Springs, NC 27540-7776
Phone (919) 567-6120

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address cwallace966346@direct.UNC.nchie.net Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20220928000259 NC Practitioner - Physician Assistant 9032595194 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2022
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Duke University Health System, IncGroup PAC ID 2567372345, shared by 22 NPIs, 1,083 clinicians

Practice addresses (Care Compare)

2301 Erwin Rd
Durham, NC 27705-4699
Phone (919) 684-8111

3400 Wake Forest Rd
Raleigh, NC 27609-7317
Phone (919) 954-3965

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Duke University Health System, Inc. CurrentSince Nov 1, 2024 Accepting new patients
Duke University Health System, Inc. CurrentSince Nov 1, 2024 Accepting new patients
Rex Hospital Inc Past Accepting new patients

Locations

2301 Erwin Rd
Durham, NC 27705
Phone (919) 668-0289

3643 N Roxboro St
Durham, NC 27704
Phone (919) 470-6186

40 Duke Medicine Cir
Durham, NC 27710
Phone (919) 681-6588

3400 Wake Forest Rd
Raleigh, NC 27609
Phone (919) 954-3000

Interoperability endpoints

  • Direct secure messaging: cwallace966346@direct.unc.nchie.net

Organizations & group practices 8

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

Hospital & facility affiliations 2

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

NPI Registry JSON

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

{
    "created_epoch": "1656028800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1695772800000",
    "number": "1396477840",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1218 MAROON DR",
            "city": "DURHAM",
            "state": "NC",
            "postal_code": "277138233",
            "telephone_number": "702-596-9122"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "566 RUIN CREEK RD",
            "city": "HENDERSON",
            "state": "NC",
            "postal_code": "275362927",
            "telephone_number": "919-461-0017"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "781 Avent Ferry Rd Ste 102",
            "address_purpose": "LOCATION",
            "city": "Holly Springs",
            "state": "NC",
            "postal_code": "275407776",
            "country_code": "US",
            "telephone_number": "919-567-6120",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "COLBY",
        "middle_name": "RIP",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2022-06-24",
        "last_updated": "2023-09-27",
        "certification_date": "2023-09-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-12596",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "cwallace966346@direct.UNC.nchie.net",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CDA/CCD/TXT",
            "address_1": "781 Avent Ferry Rd Ste 102",
            "city": "Holly Springs",
            "state": "NC",
            "country_code": "US",
            "postal_code": "275407776",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Henderson, NC

Sources for this page

Verify at the official NPI Registry.