Ellis J Wallace, PA-C

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

002533 Issued in GA

Practice address

1061 Harmon Ave
Fort Stewart, GA 31314-5641

Phone

(912) 435-6633

Fax

(912) 435-5379

NPI assigned

Oct 19, 2006

Last updated

Mar 10, 2011By the provider in NPPES

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

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

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.

• Boston Heart Diagnostics Corporation

  • Clinical Medical Laboratory
  • Lenexa, KS
  • NPI 1922259753
  NPD (past)

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

{
    "created_epoch": "1161216000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1299715200000",
    "number": "1538241815",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1061 HARMON AVE",
            "address_2": "STE 1 D03",
            "city": "FORT STEWART",
            "state": "GA",
            "postal_code": "31315",
            "telephone_number": "912-435-6633",
            "fax_number": "912-435-5379"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1061 HARMON AVE",
            "city": "FORT STEWART",
            "state": "GA",
            "postal_code": "313145641",
            "telephone_number": "912-435-6633",
            "fax_number": "912-435-5379"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "ELLIS",
        "middle_name": "J",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-10-19",
        "last_updated": "2011-03-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "GA",
            "license": "002533",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00560436K",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• James S Walker, RN
• Jessie Walker, EMT MEDIC
• Kareem Walker
• Koren Walker, LVN
• Aliyah Wall
• Amandalea Rhiannon Walsh, LCSW, LISW-CP
• Elliott Blair Walsh, O.D.
• Andrea Chelee Walthour, LPN
• Kim A Ware, DNP
• Nikiya Warner

• Medical Physician Assistant in Fort Stewart, GA
• Providers in Fort Stewart, GA by specialty
• Medical Physician Assistant in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 10, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.