Active NPI
Dennis Lee Wallace, P.A.
- Medical Physician Assistant
- Flint, MI
National Provider Identifier
1396790986
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Medical Physician Assistant
- License
- 5601002261
- Practice address
- 4100 Beecher Rd
Suite a
Flint, MI 48532-3661 - Phone
- (810) 342-3800
- Fax
- (810) 342-3784
- NPI assigned
- May 23, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | 5601002261 | MI | Primary |
Addresses
Primary practice location
4100 Beecher Rd
Suite a
Flint, MI 48532-3661
Mailing address
4100 Beecher Rd
Suite a
Flint, MI 48532-3661
Phone (810) 342-3800
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5601002261 | MI | MD | Medical Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1148342400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1281484800000",
"number": "1396790986",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4100 BEECHER RD",
"address_2": "SUITE A",
"city": "FLINT",
"state": "MI",
"postal_code": "485323661",
"telephone_number": "810-342-3800",
"fax_number": "810-342-3784"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4100 BEECHER RD",
"address_2": "SUITE A",
"city": "FLINT",
"state": "MI",
"postal_code": "485323661",
"telephone_number": "810-342-3800",
"fax_number": "810-342-3784"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "DENNIS",
"middle_name": "LEE",
"credential": "P.A.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-23",
"last_updated": "2010-08-11",
"status": "A"
},
"taxonomies": [
{
"code": "363AM0700X",
"taxonomy_group": "",
"desc": "Physician Assistant, Medical",
"state": "MI",
"license": "5601002261",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Flint, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 11, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.