John David Wallace, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

5601006422 Issued in MI

Practice address

601 Bridge St
East Jordan, MI 49727-9383

Phone

(231) 536-2206

Fax

(231) 536-7150

NPI assigned

Jul 15, 2012

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

Enrolled in MI

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

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: john.wallace.p1@direct.ejfhc.nextgenshare.com
• FHIR API: https://fhir.nextgen.com/nge/prod/fhir-api-r4/fhir/r4/
• Direct secure messaging: john.wallace.p1@direct.alcona.nextgenshare.com

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.

• Alcona Citizens for Health, Inc.

  • Federally Qualified Health Center (FQHC)
  • Harrisville, MI
  • NPI 1326055450

  MI, Physician Assistant

  Medicare reassignment NPD
• East Jordan Family Health Center

  • Federally Qualified Health Center (FQHC)
  • East Jordan, MI
  • NPI 1114958691

  MI

  Medicare reassignment NPD (past)
• Alcona Citizens for Health, Inc.

  • Federally Qualified Health Center (FQHC)
  • Alpena, MI
  • NPI 1750159158
  NPD
• East Jordan Family Health Center

  • Federally Qualified Health Center (FQHC)
  • Bellaire, MI
  • NPI 1376750091
  NPD
• Indigo Hospital Medicine - Alpena, PLC

  • Internal Medicine Physician
  • Alpena, MI
  • NPI 1740411461
  NPD (past)

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

{
    "created_epoch": "1342310400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1663632000000",
    "number": "1487909511",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "601 BRIDGE ST",
            "city": "EAST JORDAN",
            "state": "MI",
            "postal_code": "497279383",
            "telephone_number": "231-536-2206",
            "fax_number": "231-536-7150"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "601 BRIDGE ST",
            "city": "EAST JORDAN",
            "state": "MI",
            "postal_code": "497279383",
            "telephone_number": "231-536-2206",
            "fax_number": "231-536-7150"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "6135 Cressy St",
            "address_purpose": "LOCATION",
            "city": "Indian River",
            "state": "MI",
            "postal_code": "497495151",
            "country_code": "US",
            "telephone_number": "231-238-8908",
            "fax_number": "231-238-4419",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "JOHN",
        "middle_name": "DAVID",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-07-15",
        "last_updated": "2022-09-20",
        "certification_date": "2022-09-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MI",
            "license": "5601006422",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• All providers in East Jordan, MI
• Physician Assistant in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 20, 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.