Anya Wallace, PA-C

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

0010-05473 Issued in NC

Practice address

309 S Sharon Amity Rd.
Suite 206
Charlotte, NC 28211

Phone

(704) 360-5018

Fax

(980) 273-1102

NPI assigned

Jan 5, 2015

Sex

Female

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

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Oct 1, 2021 through Oct 1, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Interoperability endpoints

• Direct secure messaging: anya.wallace@180054839525380.direct.elationemr.com

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

{
    "created_epoch": "1420416000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1626220800000",
    "number": "1609264373",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "309 S SHARON AMITY RD.",
            "address_2": "SUITE 206",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "28211",
            "telephone_number": "704-360-5018",
            "fax_number": "980-273-1102"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "309 S SHARON AMITY RD.",
            "address_2": "SUITE 206",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "28211",
            "telephone_number": "704-360-5018",
            "fax_number": "980-273-1102"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "ANYA",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2015-01-05",
        "last_updated": "2021-07-14",
        "certification_date": "2021-07-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-05473",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NC",
            "license": "0010-05473",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Randolph Carey Wall, PH.D.
• Debbie Ann Wallace-Pratt, LCSWA
• Alysen Janae Wallace, MS, LPCA
• Andrea Nicole Wallace, FNP
• Anna Odessa Wallace
• Barbara Mary Wallace, LCSWA
• Caleb Wallace, DPT
• Chloe Wallace
• Courtni Wallace
• Cynthia C Wallace, MA, LCMHCS, NCC

• Medical Physician Assistant in Charlotte, NC
• Providers in Charlotte, NC by specialty
• Medical Physician Assistant in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 14, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.