Christian Alexander Wallace, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

5111 Issued in TN

Practice address

507 N 17TH Street
Milwaukee, WI 53233

Phone

(414) 288-5688

NPI assigned

Mar 17, 2022

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in TN

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

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

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.

• Southeastern Emergency Physicians LLC

  • Emergency Medicine Physician
  • Maysville, KY
  • NPI 1356379382

  TN

  Medicare reassignment

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

{
    "created_epoch": "1647475200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1668988800000",
    "number": "1477201440",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "507 NORTH 17TH STREET",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "53233"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "507 N 17TH STREET",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "53233",
            "telephone_number": "414-288-5688"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "CHRISTIAN",
        "middle_name": "ALEXANDER",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2022-03-17",
        "last_updated": "2022-11-21",
        "certification_date": "2022-11-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TN",
            "license": "5111",
            "primary": true
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jill A Wall, APNP
• John P. Wall, M.D.
• Meghan Anna Wall, PH.D.
• Brian Ken Wallace, MD
• Carly Rosemary Frances Wallace
• Courtney Wallace, APSW
• Dominique Wallace
• Francheska Wallace
• Latrice Shemon Wallace, RN
• Lyndsey Wallace, PSYD

• Physician Assistant in Milwaukee, WI
• Providers in Milwaukee, WI by specialty
• Physician Assistant in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 21, 2022; 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.