Theresa A Wallace, PA-C, ATC

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA9113017 Issued in FL

Practice address

1865 Lpga Blvd
Daytona Beach, FL 32117-7108

Phone

(386) 255-4596

Fax

(386) 258-3561

NPI assigned

Jul 16, 2012

Last updated

Nov 21, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in FL

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, 2019

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Orthopaedic Clinic of Daytona Beach PAGroup PAC ID 9335123504, 48 clinicians

Ability Health Services, IncGroup PAC ID 4082523329, 1,249 clinicians

Ability Health Services and Rehabilitation LPGroup PAC ID 4981986288, shared by 2 NPIs, 1,260 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Adventhealth New Smyrna Beach Hospital, New Smyrna Beach, FL, CCN 100014
• Adventhealth Daytona Beach Hospital, Daytona Beach, FL, CCN 100068

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: theresa.adams.1@10735.direct.athenahealth.com
• FHIR API: https://api.platform.athenahealth.com/10735/brand/1/csg/1/fhir/r4

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.

• Orthopaedic Clinic of Daytona Beach PA

  • Orthopaedic Surgery Physician
  • Daytona Beach, FL
  • NPI 1558340240
  Medicare reassignment Care Compare group NPD
• Orthopaedic Clinic of Daytona Beach PA

  • Durable Medical Equipment & Medical Supplies
  • Port Orange, FL
  • NPI 1023678745
  NPD

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

• Memorial Health Systems Inc

  dba AdventHealth Daytona Beach

  • General Acute Care Hospital
  • Daytona Beach, FL
  • NPI 1063426823
  Care Compare affiliation
• Memorial Health Systems Inc

  dba AdventHealth Daytona Beach

  • Clinical Medical Laboratory
  • Daytona Beach, FL
  • NPI 1104696178

  Hospital

  Care Compare affiliation
• Southeast Volusia Healthcare Corporation

  dba AdventHealth New Smyrna Beach

  • General Acute Care Hospital
  • New Smyrna Beach, FL
  • NPI 1871977942
  Care Compare affiliation

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

{
    "created_epoch": "1342396800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1732147200000",
    "number": "1437404548",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1865 LPGA BLVD",
            "city": "DAYTONA BEACH",
            "state": "FL",
            "postal_code": "321177108",
            "telephone_number": "386-255-4596",
            "fax_number": "386-258-3561"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1865 LPGA BLVD",
            "city": "DAYTONA BEACH",
            "state": "FL",
            "postal_code": "321177108",
            "telephone_number": "386-255-4596",
            "fax_number": "386-258-3561"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1890 Lpga Blvd Ste 240",
            "address_purpose": "LOCATION",
            "city": "Daytona Beach",
            "state": "FL",
            "postal_code": "321177131",
            "country_code": "US",
            "telephone_number": "386-255-4596",
            "fax_number": "386-258-3561",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1325 San Marco Blvd",
            "address_2": "SUITE 102",
            "address_purpose": "LOCATION",
            "city": "Jacksonville",
            "state": "FL",
            "postal_code": "322078568",
            "country_code": "US",
            "telephone_number": "904-858-7045",
            "fax_number": "904-858-7047",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1165 Dunlawton Ave Ste 102",
            "address_purpose": "LOCATION",
            "city": "Port Orange",
            "state": "FL",
            "postal_code": "321272924",
            "country_code": "US",
            "telephone_number": "386-255-4596",
            "fax_number": "386-258-3561",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1175 Dunlawton Ave Ste 1",
            "address_purpose": "LOCATION",
            "city": "Port Orange",
            "state": "FL",
            "postal_code": "321274741",
            "country_code": "US",
            "telephone_number": "386-255-4596",
            "fax_number": "386-258-3561",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "17 Old Kings Rd N Ste K",
            "address_purpose": "LOCATION",
            "city": "Palm Coast",
            "state": "FL",
            "postal_code": "321378283",
            "country_code": "US",
            "telephone_number": "386-255-4596",
            "fax_number": "386-258-3561",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1075 Mason Ave",
            "address_purpose": "LOCATION",
            "city": "Daytona Beach",
            "state": "FL",
            "postal_code": "321174611",
            "country_code": "US",
            "telephone_number": "386-255-4596",
            "fax_number": "386-258-3561",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "THERESA",
        "middle_name": "A",
        "credential": "PA-C, ATC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-07-16",
        "last_updated": "2024-11-21",
        "certification_date": "2024-11-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "FL",
            "license": "AL2836",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "FL",
            "license": "PA9113017",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "105958900",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kaitlyn E Walker
• Robyn Heath Walker
• Gail Jean Wall, PA
• Ebonie Wallace
• Grant Wallace, DPT
• Molly Wallis, APRN FNP-C
• Julia Wallrich
• Kimberly Paige Walter
• Laura Michelle Walton, DPM
• Paige Ward

• Physician Assistant in Daytona Beach, FL
• Providers in Daytona Beach, FL by specialty
• Physician Assistant in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 21, 2024; 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.